Assessment of the Musculoskeletal System – Advanced

by Stephen Holt, MD, MS

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    00:01 Alright, so now we're going to jump into the examination of the neck, the low back and the hips.

    00:09 First off, when we're doing inspection of the upper back, we're trying to look for the normal curvature of the spine.

    00:15 The spine is not just a straight rod from top to bottom, it actually has some natural curvature to it.

    00:21 So Shawn, if you could rotate about 45 degrees this way.

    00:26 You can see right off the bat, that he has what's called a normal kyphosis, which is right here.

    00:32 It's just this curvature around the cervical thoracic spine.

    00:36 If a person has significant vertebral insufficiency from osteoporotic fractures, you may find them, curve your spine forward a bit for me and tear on top.

    00:46 Great.

    00:46 So you'd have excess kyphosis, as the spine sort of folds forward due to loss of the vertebral height in the cervical spine.

    00:53 So this is the normal kyphotic curve here.

    00:56 And then down here, there's also a curvature in the lumbosacral area where the lumbosacral spine is somewhat concave.

    01:04 And that's the normal lordosis of the spine.

    01:07 Patients who have significant back spasm, for example, may have strong contraction of the spinous muscles, the paraspinal muscles down there that would cause in a particularly severe straightening of the spine in this area and loss of the normal lordosis of the spine.

    01:25 All right, facing forward again for me.

    01:28 Inspection would also include looking at the skin, you'd hate to have a patient come in with a back pain problem, and you don't take their shirt off.

    01:35 And then later on, you realize they just had shingles, you know, from some acute zoster issue.

    01:39 So always be sure you're taking a look at the patient's skin whenever you're doing an assessment for pain.

    01:45 Next up, we're going to go through range of motion.

    01:48 So there's 3 degrees really of motion around the head and also the neck.

    01:54 And some of them are more useful than others.

    01:56 So first I'm going to do is just twisting, so I want you to twist to the right, all the way to the right, that right, and then all the way to the left.

    02:05 So it turns out that twisting is not a particularly useful measure because it doesn't tell us anything about what's causing a patient's pain.

    02:13 Nonetheless, we do it to kind of get a degree of the severity of their discomfort and it's something you could potentially track over time if you're a physical therapist and monitoring such things.

    02:22 The next range of motion is forward and an extension of the spine.

    02:26 So I'm going to have you face to the wall, and I want you to flex all the way forward.

    02:31 This is particularly useful not only because we can look for scoliosis, you're going to look to see if there's any curvature of the spine.

    02:37 But in addition, if somebody has scoliosis, there'll be an asymmetry in the height of the paraspinal muscles on one side.

    02:45 Scoliosis really becomes more evident when you have a patient lean forward because you'll see a prominence on the left or prominence on the right with abnormalities in you know, lateral bending of the spine.

    02:58 So the two tests that we're going to use to assess for SI joint disease are the FABER and the sacral compression test.

    03:06 FABER is actually just an acronym that tells me what I'm supposed to do for this test.

    03:10 It's an acronym for flexion, abduction, and external rotation of the hip.

    03:16 And if you put the first letter from each of those words together, you get FABER.

    03:20 So flexion.

    03:23 Abduction, which is moving the hip away, and then external rotation, and it essentially forms a figure 4.

    03:30 And I'm going to have you just bring your knee down to the table as far down as you can go.

    03:35 And what we're trying to do here is to see if the strain that I'm applying, especially when I push here on the other hip, the strain that I'm applying isn't reproducing any pain in the sacro iliac joints posteriorly.

    03:47 If doing this just causes pain in a patient's growing, that's got nothing to do with the SI joints, it's more likely that they're tight hamstrings or some potentially disease of the hip itself.

    03:56 But when we're doing this test, we're trying to see if this reproduces posterior pain.

    04:01 The second test that we're going to do is the sacral compression test and I'll have you roll over onto your left hip please.

    04:11 The sacrum essentially looks like two wings that are joined together at the sacrum.

    04:17 And at the two joints, the SI joints and by pushing down on his hips, we are flexing and putting tension on the junction between the ala, the wings of the hips and the SI joints.

    04:29 So simply finding this anterior superior iliac spine which is here, just part of his hips, part of his pelvic bone.

    04:37 I'm going to push down and we're trying to see if this motion reproduces any pain at the SI joints, which I am flexing by pushing down on his sacrum like that.

    04:50 Keep in mind that if this just causes pain, where I'm applying pressure that has nothing to do with the SI joints.

    04:56 So those are the two tests for sacroiliac disease.

    04:59 Now I want to do one quick test for piriformis syndrome.

    05:03 So with piriformis syndrome, what's happening is that as the sacral nerves from the sacral plexus and most notably the sciatic nerve exits the pelvis, they're passing around the piriformis muscle, which if it's inflamed or very tight can cause inflammation and ultimately, entrapment of the sciatic nerve causing pain, most notably in the buttock area, particularly when you're just talking about small branches of the sciatic nerve.

    05:32 So, this test is designed to activate the piriformis muscle to have it contract.

    05:38 And if that reproduces the patient's buttock pain, it supports the diagnosis of piriformis syndrome.

    05:43 So why don't we have you do is lift up your leg, put your shoe down on the table, and I want you to apply downward pressure like you're driving your foot into the table while I push away like this.

    05:53 So there's two actions that are happening here, I am resisting, external rotation and abduction of his hip while he's driving down his foot into the table.

    06:02 This is essentially contracting his piriformis muscle.

    06:05 You can relax now.

    06:06 If that were to reproduce pain back here on his buttock area where the piriformis muscle is very deep to this, the gluteus maximus that would support the diagnosis of piriformis syndrome.

    06:17 Since we're in this position, now we can talk about lateral causes of hip pain.

    06:22 The most, notable the most common of which is certainly trochanteric bursitis.

    06:27 I'm going to grab my model here demonstrate this.

    06:33 So this is a right hip, and again, this is the entire pelvic bone.

    06:37 And this is the femur.

    06:39 And this is the greater trochanter of that femur.

    06:42 So if we line this up with his anatomy, here's the pubic symphysis which would wrap around to there, and this is the anterior superior iliac spine.

    06:50 Patients oftentimes report that they have hip pain, but it actually has nothing to do with the hip joint.

    06:55 Instead, it's inflammation over this greater trochanter where there's a bursa, your trochanteric bursa, that can commonly get inflamed as tendons and muscles, like the tensor fascia lata course across it, particularly if somebody has an ankle injury or a knee injury, and they start walking funny.

    07:15 More specifically, an antalgic gait.

    07:19 The mechanics of their ambulation start to impact how muscles and tendons are aligned.

    07:24 And that malalignment can cause irritation over the bursa over the greater trochanter.

    07:29 And so they'll have pain right in that area.

    07:32 And luckily, it's extremely easy to diagnose, you're basically just going to look for the most prominent, the bony prominence over the lateral thigh, and you'll find that bony prominence very easily and just pushing on that area.

    07:46 You'll see if that reproduces the patient's hip pain, and then you know you've got your diagnosis.

    07:51 So the next one to go over since we're in this position, and I'll actually have you lie on your back now, Shawn, is entrapment of a different nerve.

    08:00 In this case, it's the lateral femoral cutaneous nerve.

    08:03 The lateral femoral cutaneous nerve, as you may remember, it passes just deep to the inguinal ligament.

    08:08 So I want you to envision here the inguinal ligament that lies connects between the pubic symphysis and over here to the anterior superior iliac spine.

    08:17 So there's an invisible line connecting those.

    08:20 And the lateral femoral cutaneous nerve dives just deep to that inguinal ligament and comes out and innervates the entire anterolateral thigh.

    08:31 So patients who have...

    08:35 So patients who report that they're having paraesthesias in this lateral and anterior location in a sort of a predictable distribution shown here will oftentimes simply have lateral femoral cutaneous nerve entrapment.

    08:48 It's also known as Meralgia paresthetica.

    08:51 It's relatively common, particularly in folks who wear very tight fitting jeans or tight belt, backpackers wear those tight belts so that they can carry around 40 pounds of weight on their back.

    09:04 Patients who are pregnant, folks who are obese and potentially have just extra panis that would be pushing down on those areas as well.

    09:14 Any of those things can cause an entrapment injury to this nerve.

    09:18 And one typical way that you can try to identify it other than simply identifying where the patient's paraesthesias are located is you can actually perform a test where you tap on the location of that lateral femoral cutaneous nerve as it passes just medial to the anterior superior iliac spine, and in an attempt to try and reproduce those burning paraesthesias going down the thigh.

    09:39 You could also simply do pinprick testing, comparing one side to the other or any other type of sensory testing since it is a sensory nerve, and you may be able to detect subtle differences from one side to the other.

    09:53 Lastly, let's talk about anterior hip pain.

    09:56 Acknowledging that lateral femoral cutaneous nerve entrapment is really intelateral but in any event, let's focus on anterior hip pain.

    10:03 Patients who actually have hip disease will typically report anterior hip pain or growing pain.

    10:11 That is some discomfort at the junction where the legs meet the perineum.

    10:18 If we're trying to look for osteoarthritis of the hip, there's a few classic manoeuvres that are likely to confirm that diagnosis or certainly support that diagnosis.

    10:27 One of which is that patients who have significant osteoarthritis of the hip joints will have difficulties with internal rotation, and you can simply log roll a person's leg like this and to see to what extent they can inward rotate their leg.

    10:45 Patients with advanced osteoarthritis may only have 10 degrees of rotation, which is a very small amount of rotation before they have significant discomfort or simply cannot do it.

    10:54 Whereas most people should be able to roll in almost 45 degrees.

    11:00 Just doing a simple log roll.

    11:02 So in addition to just doing that internal rotation log roll, the remaining range of motion of the hip exam is going to include flexion.

    11:12 Extension, which oftentimes requires laying the patient on one side so you can really bring their leg behind them.

    11:17 And then adduction and abduction.

    11:22 Patients with osteoarthritis will typically have their pain reproduced with abduction, and adduction.

    11:28 And that can be very useful diagnostic test.

    11:32 External rotation of the hip is performed by turning it's kind of counterintuitive because I'm turning the ankle inward towards the camera.

    11:39 But in so doing, I'm rotating the hip joint out.

    11:42 So that's external rotation of the hip.

    11:47 So the last disease that I wanted to cover that involves anterior hip pain involves those very important muscle flexors, those hip flexors in the anterior area of the hip joint, and those are, of course, the iliopsoas muscles.

    12:03 Again, if this is my hip joint and this is my inguinal ligament attaching between the asis and the pubic symphysis.

    12:09 The iliopsoas muscle is the major muscle group that is passing just deep the inguinal ligament and ultimately attaching further down on the femur.

    12:18 And that's the real power that allows us to powerfully flex up our hips.

    12:23 Patients who have iliopsoas bursitis will have discomfort simply by palpating over the inguinal ligament.

    12:31 And whether it's iliopsoas bursitis or an iliopsoas muscle strain or even a muscle tear.

    12:36 If you have them lift up their knee against resistance.

    12:38 Lift up your thigh for me, please.

    12:40 Pushing down like that, which is again I'm resisting their iliopsoas muscle, that should really be able to very clearly reproduce their discomfort.

    12:49 So that wraps up our examination of the hip.

    About the Lecture

    The lecture Assessment of the Musculoskeletal System – Advanced by Stephen Holt, MD, MS is from the course Assessment of the Musculoskeletal System (Nursing).

    Included Quiz Questions

    1. The cervical spine typically has a lordotic curve and the thoracic spine has a kyphotic curve.
    2. Some kyphosis of the lumbar spine is normal.
    3. Some lordosis of the thoracic spine is normal.
    4. Any lordosis of the lumbar spine is abnormal.
    1. Bend at the waist
    2. Twist from side to side
    3. Lie prone
    4. Lie supine
    1. Sacroiliac joint disease
    2. Scoliosis
    3. Kyphosis
    4. Piriformis syndrome
    1. Trochanteric bursitis
    2. Sacroiliac joint disease
    3. Piriformis syndrome
    4. Scoliosis
    1. Meralgia paresthetica
    2. Bursitis
    3. Sacroiliac pain
    4. Cauda equina
    1. Decreased internal rotation of the hip
    2. Pain with adduction of the leg
    3. Increased flexion of the hip
    4. Increased external rotation of the hip
    5. Relief of pain with abduction of the leg

    Author of lecture Assessment of the Musculoskeletal System – Advanced

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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