Range Of Motion And Maneuvers

Range of motion at the ankle includes flexion and extension at the ankle (tibiotalar) joint and, in the foot, inversion and eversion at the subtalar and transverse tarsal joints.

■ The Ankle (Tibiotalar) Joint. Dorsiflex and plantar flex the foot at the ankle.

Pain during movements of the ankle and the foot helps to localize possible arthritis.

■ The Subtalar (Talocalcaneal) Joint. Stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot.

INVERSION EVERSION

An arthritic joint is frequently painful when moved in any direction, while a ligamentous sprain produces maximal pain when the ligament is stretched. For example, in a common form of sprained ankle, inversion and plantar flexion of the foot cause pain, while eversion and plantar flexion are relatively pain free.

INVERSION EVERSION

■ The Transverse Tarsal Joint. Stabilize the heel and invert and evert the forefoot.

■ For the Metatarsophalangeal joints, flex the toes in relation to the feet.

INVERSION EVERSION

M Special Techniques

For the Carpal Tunnel Syndrome. Pain and numbness on the ventral surface of the first three digits of the hand (but not in the palm), especially at night, suggest median nerve compression in the carpal tunnel, which lies between the carpal bones dorsally and a ventral band of more superficial fascia, the flexor retinaculum.

Appropriate symptoms and objective loss of sensation on the ventral surface of the hand in the distribution of the median nerve (see p. 473 and p. 474), and weak abduction of the thumb on muscle strength testing are the most helpful for making the diagnosis. Two additional clinical tests are also used— when positive, Tinel's test appears more likely to be confirmed by further diagnostic testing.

Thumb Abduction. Ask the patient to raise the thumb perpendicular to the palm as you apply downward pressure on the distal phalanx. (This maneuver reliably tests the strength of the abductor pollicis bre-vis, which is innervated only by the median nerve.)

Tinel's Sign. With your finger, percuss lightly over the course of the median nerve in the carpal tunnel at the spot indicated by the arrow.

Tingling or electric sensations in the distribution of the median nerve constitute a positive test, suggesting carpal tunnel syndrome.

Onset often related to repetitive motion with wrists flexed (e.g., keyboard use, mail-sorting), pregnancy, rheumatoid arthritis, diabetes, hypothyroidism

Thenar atrophy may also be present.

Tingling or electric sensations in the distribution of the median nerve constitute a positive test, suggesting carpal tunnel syndrome.

Phalen's Test. Hold the patient's wrists in acute flexion for 60 seconds. Alternatively, ask the patient to press the backs of both hands together to form right angles. These maneuvers compress the median nerve.

Low Back Pain Due Hypothyroidism

If numbness and tingling develop over the distribution of the median nerve (e.g., the palmar surface of the thumb, and the index, middle, and part of the ring fingers), the sign is positive, suggesting carpal tunnel syndrome.

For Low Back Pain With Radiation Into the Leg. If the patient has noted low back pain that radiates down the leg, check straight leg raising on each side in turn. The patient should be lying supine. Raise the patient's relaxed and straightened leg until pain occurs. Then dorsiflex the foot.

Record the degree of elevation at which pain occurs, the quality and distribution of the pain, and the effects of dorsiflexion. Tightness and mild discomfort in the hamstrings with these maneuvers are common and do not indicate radicular pain.

Back Pain Physical Exam

Sharp pain radiating from the back down the leg in an L5 or S1 distribution (radicularpain) suggests tension on or compression of the nerve root(s), often caused by a herniated lumbar disc. Dorsiflexion of the foot increases the pain. Increased pain in the affected leg when the opposite leg is raised strongly confirms radicular pain and constitutes a positive crossed straight leg-raising sign.

Examine the patient neurologically, focusing on the motor and sensory functions and the reflexes at the lumbosacral levels. These are outlined in the next chapter.

Measuring the Length of Legs. If you suspect that the patient's legs are unequal in length, measure them. Get the patient relaxed in the supine

Unequal leg length may explain a scoliosis.

position and symmetrically aligned with legs extended. With a tape, measure the distance between the anterior superior iliac spine and the medial malle-olus. The tape should cross the knee on its medial side.

Describing Limited Motion of a Joint. Although measurement of motion is seldom necessary, limitations can be described in degrees. Pocket goniometers are available for this purpose. In the two examples shown below, the red lines indicate the range of the patient's movement and the black lines suggest the normal range.

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