Cervical Spine Evaluation Module

Subjective/History
Determine : activity, MOI, location of pain or neurologic symptoms, reports of weakness, type of pain, severity of pain, onset of pain, unusual sounds/sensations, actions that increase & decrease pain, S/S, change in S/S over time, prior injury/surgery, prior treatment, family history & general medical health
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Objective
Inspection
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General: swelling, discoloration, deformity, muscle symmetry/atrophy Skin: blisters, discoloration, open wounds, scars & skin infections Anterior View: posture including: shoulder height, muscle symetry, muscle tone Posterior View: posture including: shoulder height, muscle symetry, muscle tone Lateral View: posture including: head position, shoulder position, cervical curve, thoracic curve, muscle tone Low Back Palpation Rollover: using internet explorer rollover the images to trace some anatomy of the low back Bony Palpation & Soft Tissue Palpation : hyoid, thyroid cartilage, first cricoid ring, carotid tubercle, occiput, inion, superior nuchal line, mastoid process, cervical spinous processes, facet joints, sternocleicomastoid, lymph chain, thyroid gland, carotid pulse, parotid gland, supraclavicular fossa, trapezius, lymph nodes, greater occipital nerves & superior nuchal ligament Range of Motion
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AROM: flexion, extension, lateral flexion, rotation PROM: flexion, extension, lateral flexion, rotation RROM: flexion, extension, lateral flexion, rotation Manual Muscle Testing : Sternocleidomastoid, Cervical Extensors, Upper Trapezius Neurovascular Exam Special Tests
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Brachial Plexus Traction/Compression, Nerve Root Compression/Spurlings, Valsalva, Vertebral Artery Syndrome, Tap/Bump

Assessment
Identifies examiner's impression of injury & potientally complicating factors based on subjective & objective information

Plan

Explains examiner's goals as well as how the examiner intends on meeting these goals through initial managent, treatment, rehabilitation

Manual Muscle Testing

Gluteus Maximus
Origin Posterior gluteal line of ilium and portion of bone superior and posterior to it, posterior surface of lower part of sacrum, side of coccyx, aponeurosis of erector spinae, sacrotuberous ligament, and gluteal aponeurosis Insertion Larger proximal portion and superficial fibers of distal portion of muscle into iliotibial tract of fascia lata Deep fibers of distal portion into gluteal tuberosity of femur Action Extends, laterally rotates, and lower fibers assist in adduction of the hip joint The upper fibers assist in abduction Through its insertion into the iliotibial tract, helps to stabilize the knee in extension Nerve Inferior glueteal L5, S12 Patient Prone with knee flexed 90 or more (The more the knee is flexed, the less the hip will extend, due to restricting tension of the Rectus femoris anteriorly) Fixation Posteriorly, the back muscles, laterally, the lateral abdominal muscles, and, anteriorly, the opposite hip flexors fix the pelvis to the trunk Test Hip extension with knee flexed Pressure Against the lower part of the posterior thigh in the direction of hip flexion See Test

Gluteus Medius
Origin External surface of ilium between iliac crest and posterior gluteal line dorsally, and anterior gluteal line ventrally, gluteal aponeurosis Insertion

Oblique ridge on lateral surface of greater trochanter of femur Action Abducts the hip joint The anterior fibers medially rotate and may assist in flexion of the hip joint; the posterior fibers laterally rotate and may assist in extension Nerve Superior gluteal L45, S1 Patient Sidelying with underneath leg flexed at hip and knee, and pelvis rotated slightly forward to place the posterior Gluteus medius in an antigravity position Fixation The muscles of the trunk and the examiner stabilize the pelvis Test (emphasis on posterior portion) Abduction of hip with slight extension and slight external rotation Knee is maintained in extension Pressure Against the leg, near the ankle, in the direction of adduction and slight flexion; do not apply pressure against the rotation component See Test

Gluteus Minimus
Origin External surface of ilium between anterior and inferior gluteal lines, and margin of greater sciatic notch Insertion Anterior border of greater trochanter of femur, and hip joint capsule Action Abducts, medially rotates, and may assist in flexion of the hip joint Nerve Superior gluteal L45, S1 Patient Sidelying Fixation The examiner stabilizes the pelvis Test Abduction of the hip in a position neutral between flexion and extension, and neutral in regard to rotation

Pressure Against the leg in the direction of adduction and very slight extension See Test

Hip Adductors (Pectineus, Adductor magnus, Gracilis, Adductor brevis, Adductor longus)
Action Adduction of the hip joint In addition, the Pectineus, Adductor brevis, and Adductor longus flex the hip joint Patient Lying on the right side to test right (and vice versa), body in straight line, with lower extremities and lumbar spine straight Fixation The examiner holds the upper leg in abduction The patient should hold on to the table for stability Test Adduction of the underneath extremity upward from the table without rotation, flexion, or extension of the hip, or tilting the pelvis Pressure Against the medial aspect of the distal end of the thigh in the direction of abduction Pressure is applied at a point above the knee to avoid strain of the tibial collateral ligament See Test

Hip Internal Rotators (Tensor fasciae latae, Gluteus minimus, and Gluteus medium)
Action Medial rotation of the hip joint Patient Sitting on a table with knees bent over side of table, holding on to table Fixation The weight of the trunk stabilizes the patient during this test Stabilization is also given in the form of counterpressure as described below under Pressure Test Medial rotation of the thigh, with the leg is position of completion of outward arc of motion Pressure Counterpressure is applied by one hand of the examiner at the medial side of the lower end of the thigh The other hand of the examiner applies pressure to the lateral side of the leg above the ankle, pushing the leg inward in an effort to rotate the thigh laterally

See Test

Iliopsoas
Origin Ventral surfaces of transverse processes of all lumbar vertebrae, sides of the bodies and corresponding interverebral discs of the last thoracic and all lumbar vertebrae and membranous arches that extend over the sides of the bodies of the lumbar vertebrae Insertion Lesser trochanter of femur Nerve Lumbar plexus L14 Action With the origin fixed, the Iliopsoas flexes the hip joint by flexion the femur on the truck as in supine alternate leg raising, and may assist in lateral rotation and abduction of the hip joint With the insertion fixed and acting bilaterally, the Iliopsoas flexes the hip joint by flexion the trunk on the femur as in the situp from supine position Also, acting bilaterally with the insertion fixed, will increase the lumbar lordosis; acting unilaterally, assists in lateral flexion of the trunk toward the same side Patient Supine Fixation The examiner stabilizes the opposite iliac crest The Quadriceps stabilize the knee in extension Test Hip flexion in a position of slight abduction and slight lateral rotation Pressure Against the anteromedial aspect of the leg in the direction of extension and slight abduction See Test

Biceps Femoris
Origin of Long Head Distal part of sacrotuberous ligament, and posterior part of tuberosity of ischium Origin of Short Head Lateral lip of linea aspera, proximal two thirds of upracondylar line, and lateral intermuscular septum Insertion Lateral side of head of fibula, lateral condyle of tibia, deep fascia on lateral side of leg Action

The long and short heads of the Biceps femoris flex and laterally rotate the knee joint In addition, the long head extends and assists in lateral rotation of the hip joint Nerve to Long Head Sciatic (tibial branch) L5, S13 Nerve to Short Head Sciatic (peroneal branch) L5, S12 Patient Prone Fixation The examiner should hold the thigh firmly down on the table Test Flexion of the knee between 50 and 70 with the thigh in slight lateral rotation, and the leg in slight lateral rotation on the thigh Pressure Against the leg proximal to the ankle in the direction of knee extension Do not apply pressure against the rotation component See Test

Semitendinosus
Origin Tuberosity of ischium by tendon common with long head of Biceps femoris Insertion Proximal part of medial surface of body of tibia, and deep fascia of leg Action Flexes and medially rotates the knee joint Extends and assists in medial rotation of the hip joint Nerve Sciatic (tibial branch) L45, S12 Patient Prone Fixation The examiner should hold the thigh firmly on the table Test Flexion of the knee between 50 and 70 with the thigh in medial rotation, and the leg medially rotated on the thigh Pressure

Against the leg proximal to the ankle in the direction of knee extension Do not apply pressure against the rotation component See Test

Semimembranosus
Origin Tuberosity of ischium, proximal and lateral to Biceps femoris and Semitendinosus Insertion Posteromedial aspect of medial condyle of tibia Action Flexes and medially rotates the knee joint Extends and assists in medial rotation of the hip joint Nerve Sciatic (tibial branch) L45, S12 Patient Prone Fixation The examiner should hold the thigh firmly on the table Test Flexion of the knee between 50 and 70 with the thigh in medial rotation, and the leg medially rotated on the thigh Pressure Against the leg proximal to the ankle in the direction of knee extension Do not apply pressure against the rotation component See Test

Quadriceps
Origin of Rectus Femoris Straight head from anterior inferior iliac spine Reflected head from groove above rim of acetabulum Origin of Vastus Lateralis Proximal part of intertrochanteric line, anterior and inferior borders of greater trochanter, lateral lip of gluteal tuberosity, proximal one half of lateral lip of linea aspera, and lateral intermuscular septum Origin of Vastus Intermedius Anterior and lateral surfaces of proximal two thirds of body of femur, distal one half of linea aspera, and lateral intermuscular septum Origin of Vastus Medialis

Distal one half of intertrochanteric line, medial lip of linea aspera, proximal part of medial supracondylar line, tendons of Adductor longus and Adductor magnus, and medial intermuscular septum Insertion Proximal border of patella and through patellar ligament to tuberosity of tibia Nerve Femoral L24 Patient Sitting with knees over side of table, holding on to table Fixation The examiner may hold the thigh firmly down on the table, or, because the weight of the trunk is usually sufficient to stabilize the patient during this test, the examiner may put a hand under the distal end of the thigh to cushion that part against table pressure Test Extension of the knee joint without rotation of the thigh Pressure Against the leg above the ankle, in the direction of flexion See Test

Sartorius
Origin Anterior superior iliac spine and superior half of notch just distal to spine Insertion Proximal part of medial surface of tibia near anterior border Action Flexes, laterally rotates, and abducts the hip joint Flexes and assists in medial rotation of the knee joint Nerve Femoral L23 Patient Supine Fixation None necessary on the part of the examiner The patient may hold on to the table Test Lateral rotation, abduction, and flexion of the thigh, with flexion of the knee Pressure

Against the anterolateral surface of the lower thigh, in the direction of hip extension, adduction and medial rotation, and against the leg in the direction of knee extension The examiner must resist the multiple action test movement by a combined resistance movement See Test

Tensor Fascia Latae

Origin Anterior part of external lip of iliac crest, outer surface of anterior superior iliac spine, and deep surface of fascia lata Insertion Into ilitotibial tract of fascia lata at junction of proximal and middle thirds of thigh Actions Flexes, medially rotates, and abducts the hip joint; tenses the fascia lata; and may assist in knee extension Nerve Superior gluteal L45, S1 Patient Supine Fixation The patient may hold on to the table Quadriceps action is necessary to hold the knee extended Usually no fixation is necessary by the examiner, but if there is instability and the patient has difficulty in maintaining the pelvis firmly on the table, then one hand of the examiner should support the pelvis anteriorly on the opposite side Test Abduction, flexion and medial rotation of the hip with the knee extended Pressure Against the leg in the direction of extension and adduction Do not apply pressure against the rotation component See Test

Special Tests
WeberBarstow Maneuver Test
Steps Patient begins in a supine position with his/her heels off the end of the table Examiner holds the feet of the patient & places the thumbs over the medial malleoli while providing slight traction on the legs

Examiner instructs the patient to flex both knees & hips to place the feet on the table aligned next to each other (line up the medial malleoli) Examiner instructs the patient to bridge his/her hips upward and then return to his/her starting position See Maneuver

Supine to LongSit Test

Steps Patient is in a supine position with the heels off of the end of the table Examiner "clears the hips" using the WeberBarstow Maneuver Examiner passively extends the patient's legs & compares the position of the medial malleoli Examiner pulls the patient up to a longsit position from a supine position Examiner observes the position of the medial malleoli for any change from the starting position Positive Test Observable change in the position of the medial malleoli Positive Test Implications Posterior pelvic rotation (equal/short to long); anterior pelvic rotation (equal/long to short) See Test

Supine ("True") Leg Length Discrepancy Measurement Test

Steps Patient is placed in a supine Examiner "clears the hips" using the WeberBarstow Maneuver and then extends both legs Examiner measures the distance from the ASIS to the crest (i.e., highest point) of the medial malleolus on each leg OR Examiner measures the distance from the ASIS to the crest (i.e., highest point) of the lateral malleolus on each leg Positive Test Difference of greater than inch between the two legs Positive Test Implication

Possible structural leglength difference See Test

Supine "Apparent" Leg Length Discrepancy Test

See Test

Clinical Discrimination Between Femoral & Tibial Leg Length Discrepancy Test
Steps Athlete is lying supine with his/her hip flexed to 45 & knee flexed to 90 and both feet lined up next to each other (line up medial malleoli and 1st MTP joints) Examiner holds teh athlete's feet to the table and instructs the athlete to raise the pelvis up off the table and then lower the pelvis back to the table Examiner observes the patient from the side (viewing both tibial tubercles) for anterior positioning of one knee compared to the other Examiner observes the patient from the front (viewing the top of both patellae) for height differences of one knee compared to the other Positive Test Anterior positioning and/or height differences of one knee compared to the other Positive Test Implications Femoral length difference (lateral viewincreased anterior position); tibial length difference (front viewincreased height difference) See Test

Craig's Test for Femoral Anteversion/Retroversion

Steps Athlete lies prone with the knee flexed to 90 Examiner palpates the posterior aspect of the greater trochanter Measure angle formed between the vertical axis extending from the tabletop and the longitudinal axis of the lower leg Positive Tes The angle measured is outside the normal range of 815 Positive Test Implications

Excessively greater than 15 is femoral anteversion (internal torsion); excessively less than 8 is femoral retroversion (external torsion)

Gaenslen's Test
Steps Athlete is supine, lying close to the side of the table Examiner allows the near leg to hang over the side edge of the table Examiner instructs the athlete to actively flex the other leg to his/her chest & hold Examiner stabilizes the athlete & applies pressure to the near leg, forcing it into hyperextension Positive Test Pain in the SI region Positive Test Implications SI joint dysfunction See Test

Fulcrum Test
Steps Athlete is seated with his/her knees bent at the end of the table Examiner places his/her forearm or a similar bolster underneath of the athlete's midthigh Examiner uses other hand to forcefully push down on the athlete's distal anterior thigh Positive Test Athlete experiences pain in his/her thigh Positive Test Implications Possible femoral stress fracture

Nelaton's Line Test

Steps Athlete is lying supine with the knees extended Examiner draws an imaginary line from the ASIS to the ischial tuberosity (same side of the hip/pelvis) Positive Test Greater trochanter can be palpated well above the imaginary line

Positive Test Implications Coxa vara; a posteriorly dislocated hip joint See Test

Hip Scouring Test

Steps Athlete is supine Examiner fully flexes the athlete's hip & knee Examiner applies downward pressure along the femoral shaft while repeatedly externally & internally rotating the hip with multiple angles of flexion Positive Test Pain or reproduction of symptoms at the hip Positive Test Implications Defect in the articular cartilage of the femur or acetabulum See Test

Torque Test
Steps Patient lies supine & close to the edge of the table so that the involved leg can abduct over the edge of the table Examiner passively extends the involved hip (with his/her hand supporting at the ankle) until the pelvis begins to rotate anteriorly Examiner then medially rotates the hip to EROM and then places a posterolateral force at the hip joint in an attempt to distract it Positive Test Groin or lateral hip pain Positive Test Implications Sprain of the coxofemoral joint capsule or supporting ligaments See Test

Gillet's Test
Steps Athlete is standing with his/her PSISs visible

Examiner palpates the athlete's PSISs Examiner has the athlete pull one knee towards his/her chest & hold while examiner observes PSISs Positive Test Restricted side moves very little; unilateral stance is painful on the involved side Positive Test Implications SI joint pathology See Test

SI Compression Test
Steps Athlete is supine Examiner applies pressure to spread the ASIS Positive Test Pain arising from the SI joint Positive Test Implications SI pathology See Test

SI Distraction Test
Steps Athlete is in the sidelying position Examiner is positioned behind the athlete with both hands over the lateral aspect of the pelvis Examiner applies downward pressure through the anterior portion of the ilium, spreading the SI joints Positive Test Pain through the SI joint Positive Test Implications SI pathology See Test

Piriformis Tightness Test

Steps Athlete is sidelying with the test leg being the uppermost leg Athlete's test leg is flexed at the hip to about 60 & the knee flexed Examiner stabilizes the hip with one hand & applies a downward pressure to the knee Positive Test Piriformis muscle pain; buttock pain; sciatica pain Positive Test Implications Piriformis tightness (piriformis muscle pain); piriformis muscle pinching the sciatic nerve (buttock pain and sciatica pain) See Test

9090 Straight Leg Raising Test

Steps Athlete lies supine with the hips and knees flexed to 90 Athlete grasps behind both of his/her thighs to stabilize the hip joints Athlete actively extends each knee in turn Positive Test Unable to extend the knee to within 20 of full knee extension Positive Test Implications Hamstring muscle tightness See Test

Ely's Test
Steps Athlete lies prone with the knees extended Examiner passively flexes the athlete's knee Positive Test The hip on the same side passively flexes as the examiner flexes the knee Positive Test Implications Rectus femoris tightness See Test

Thomas's Test
Steps Athlete is supine with his/her knees bent at the end of the table Examiner places one hand between the lumbar lordotic curve & the tabletop Examiner passively flexes one of the athlete's legs to his/her chest, allowing the knee to flex during the movement Examiner observes the involved leg for movement Positive Test The knee of the leg on the table cannot flex past 90 (i.e. the knee of the leg on the table will extend as the examiner flexes the contralateral hip); the involved leg (i.e. the leg on the table) rises up off the table (i.e. the contralateral hip to the one being moved will flex) Positive Test Implications Rectus femoris tightness (the knee extends as the examiner flexes the hip); iliopsoas tightness (the leg on the table will rise off of the table) See Test

Patrick's Test (Faber Test or FigureFour Test)

Steps Athlete is supine with the foot of the involved side crossed over the opposite thigh (figure4 position) & the leg resting in the full external rotation Examiner has one hand on the opposite ASIS & the other hand on the medial apsect of the flexed knee Examiner applies overpressure at the knee & ASIS Positive Test Inability to lower the flexed thigh down to the level of the leg on the table; hip joint pain; Sacroiliac pain Positive Test Implications Ilipsoas tightness; hip pathology (groin or inguinal area pain); sacroiliac joint pathology (pain during application of overpressure in the SI area) See Test

Trendelenburg's Test
Steps

Athlete stands with the feet evenly distributed (i.e. approximately shoulder width apart from each other) Examiner sits or kneels behind the athlete Examiner slightly lowers the athlete's shorts so that the examiner may palpate the right & left PSIS and/or iliac crests Examiner instructs the athlete to flex the hip thereby lifting the right (and then the left knee) while observing the pelvis Positive Test The PSIS or iliac crest on the same side as the leg lifted will drop in relation to the contralateral side Positive Test Implications Contralateral (i.e., stance leg) gluteus medius (hip abductor) weakness or decreased innervation of the same muscles See Test