Where to inspect the TMJ?
1/2 cm anterior to external auditory meatus
Features associated with TMJ disorders.
chronic pain with chewing (trigeminal neuralgia, temporal arteritis), jaw clenching, or teeth grinding often associated with stress.
What to check for when feeling ROM on TMJ?
Smooth range of motion, not any swelling or tenderness, snapping or clicking, crepitus.
masseters, temporal muscles, pterygoid muscles
Pt should demonstrate: Opening and closing, protrusion and retraction, and lateral/side-to-side motion.
Rotator cuff muscles (Dynamic Stabilizers)
supraspinatus, infraspinatus, teres minor, and subscapulairs (SITS muscles)
Shoulder static stabilizers
Bony shoulder girdle (humerus, clavicle, & scapula), glenoid labrum, articular capsule, glenohumeral ligament
Glenohumeral joint, sternoclavicular joint (SC), acromioclavicular (AC) joint
Axioscapular Muscle Group
Trapezium, Rhomboids, Serratus anterior, Levator scapulae.
What does the Serratus anterior do?
protracts shoulder, rotates scapula so glenoid cavity moves superiorly
Axiohumeral muscle group
Pectoralis Minor, Latissimus dorsi, Pectoralis major. These muscles produce internal rotation of the shoulder.
What does the Pectoralis Minor do?
depresses & protracts shoulder, rotates scapula so glenoid cavity moves inferiorly, elevates ribs if scapula is stationary.
What allows the shoulder bones a wide ROM?
Articular capsule surrounding the glenohumeral joint.
Principal bursa of the shoulder?
subacromial bursa, positioned between the acromion and the head of the humerus and overlying the supraspinatus tendon.
Muscle atrophy of the suparspinatus and infraspinatus of the posterior scapula with increased prominance of scapular spine with in 2 - 3 weeks of a?
Rotator Cuff tear.
Brief, fine, irregular twitches of the muscle visible under the skin
Most common SITS muscle injured/torn?
Supraspinatus muscle (Directly under the acromion)
6 motions of the shoulder girdle
flexion, extension, abduction, adduction, internal, and external rotation.
Best predictors of rotator cuff tears?
supraspinatus weakness on abduction, infraspinatus weakness during external rotation, and a positive impingement sign.
AC joint test
Crossover test- horiz. adduct pt arm across chest w/overpressure (pain=positive). Localized tenderness suggest arthritis or inflammation of joint.
Apley scratch test
Difficulty with this test suggest rotator cuff disorder
Neer's Impingement sign
Arm pronated, scapula scapula stabilized, forced flexion. Pain = positive rotator cuff tear.
What does the "empty can test/Jobe test" identify?
weakness or insufficiency = rotator cuff tear or impingement.
Flex the pt forearm to 90 at the elbow and pronate the patient's wrist, clinician provides resistance as pt supinates the forearm & externally rotates their arm. (pain = positive inflammation of long head of biceps tendon and possible rotator cuff tear)
Hing joint - synovial diathrosis. Made of 3 bones - humerus, ulna, radius
3 articulations of elbow?
Humeroulnar joint, radiohumeral joint, radioulnar joint.
muscles that traverse the elbow?
biceps/brachioradialis (flexion), triceps (extension), pronator teres (pronation), and supinator (supination)
main bursa of the elbow?
Tenderness in lateral epicondyle
tenderness in medial epicondyle
pitcher's or golfer's elbow
ROM of elbow?
Fexion, extension, supination, and pronation.
How many carpals in the wrist?
The 2 wrist joints
Radiocarpal and intercarpal joint
contains the sheath and flexor tendons of the forearm as well as the median nerve. Flexor retinaculum holds the nerve in place
provides sensation to the palm and the palmar surface of the thumb, the second and third digits, and half of the fourth digit. It innervatest the thumb muscles of flexion, abduction, and opposition as well
Distal interphalangeal joints
Proximal interphalangeal joints
Heberden's nodes at the DIP joints
Symmetric deformity in the PIP, MCP, and wrist joints, with ulnar deviation
What to palpate on the wrist/hand
Radialcapal joint, radial styloid (anatomical snuffbox), carpals, metacarpals, phalanges
ROM for fingers and thumbs
flexion, extension, abduction, adduction, opposition
Sensation of dorsal surface on hand
radial nerve covers from the thumb to half of the ring finger, ulnar nerve covers the rest
Sensation of the volar surface of the hand
Radial nerve covers small portion of thumb, median nerve covers most of the thumb to half the ring finger, ulnar nerve cover the rest.
thoracic and sacral regions, develop during embryonic and fetal periods
cervical and lumbar, develop after birth and during infancy
Bony structures of the spine
Vertebral body, vertebral arch (transverse process, spinous process, pedicle, lamina, vertebral foramen), articular processes (articular facets), intervertebral discs.
Cushion movement between vertebrae and allow the vertebral column to curve, flex, and bend
Determines the flexibility of the spine, varies at different levels of the spine
2 types of intervertebral discs
annulus fibrosis and nucleus pulposus
2 types of articular facets
Superior and inferior
When do spasms occur?
In degenerative and inflammatory processes of muscles, prolonged contraction from abnormal posture, or anxiety
Sciatic nerve tenderness
Suggests a herniated disc or mass lesion impinging on the contributing nerve roots.
Most common herniated discs
L5 - S1 or L4-L5
Tenderness in costovertebral angles
may signify kidney infection rather than MSK problems.
May cause tenderness in intervertebral joints.
ROM for Neck
Flexion (chin to chest), Extension (look up), Rotation (look left/right), lateral bending (ear to shoulder)
Stiffness or fixation of a joint by disease or surgery
Inflammation of the vertebrae
ROM for spinal column
Extension, rotational, lateral bending
Bones of the pelvis
acetabulum, ilium, and ischium. They connect inferiorly at the symphysis pubis and posteriorly with sacroiliac bone.
joint between L5 and the base of sacrum
synovial joint of an irregular plane type between the articular surfaces of sacrum and ilium. Transmits the weight of the body to the hip bones
cartilaginous joint between the sacrum and coccyx
Cartilaginous joint between the pubic bones in the median plane
4 muscles groups of the hip
iliopsoas, gluteus maximus, (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis), (gluteus medius, gluteus minimus, piriformis)
Flexor Group of Hip
Extensor Group of Hip
Adductor Group of hip
adductor brevis, adductor longus, adductor magnus, pectineus, gracilis
Abductor group of hip
gluteus medius, gluteus minimus, piriformis
Bursae of the hip
Psoas (iliopectineal or iliopsoas), trochanteric, ischial (ishiogluteal)
Palpation landmarks of anterior hip
iliac crest, ASIS, greater trochanter, pubic symphysis
Palpation landmarks of posterior hip
PSIS, greater trochanter, sacroiliac joint
Bony structures of the knee
Medial (adductor tubercle, medial epicondyle, medial condyle), anterior (patella, patellar ligament/tendon, tibial tuberosity), lateral (lateral epicondyle, lateral condyle
How many articular surfaces in the knee?
3 lateral tibiofemoral joint, medial tibiofemoral joint, patellofemoral joint
Quadriceps femoris (rectus femoris, vastus intermedius, vastus lateralis, vastus medialis)
Hamstring muscles (biceps femoris, semimembranosus, semitendinosus, sartorius, gracilis, popliteus.
What does knee stability depend on?
menisci and 2 ligaments (collaterals and cruciates)
Bursae of the knee
Prepatellar, Anserine, Semimembranosus, others include popliteus, gastrocnemius, subcutaneous infrapatellar, deep infrapatellar.
Swelling over the tibial tubercle
inability to extend fully
Ballotting the patella
compress the suprapatellar pouch and "ballotte" or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch. Palpable fluid returning into the pouch further confirms the presence of a large effusion.
clicking/lock during flex/extension
medial meniscus test
Adduction, usually referring to testing the LCL.
Anterior Drawer Sign
Maneuver to test the ACL
Knee is flexed 15 degrees, external rotation. Elevate the tibia, depress the femur. ACL Tears
Posterior Drawer Sign
Tests for PCL tears
Bony Structures & Joints of the Ankle and Foot
Malleous (medial/lateral), calcaneus, tarsals, metatarsals, phalanges, tibiotalar joint, subtalar joint, proximal/distal interphalangeal joints.
PLantar Flexors of the ankle/foot
Gastrocnemius, posterior tibial muscles & toe extensors
Dorsiflexors of ankle/foot
anterior tibial muscle & toe extensors
fans out from the inferior surface of the medial malleoulus to the talus and proximal tarsal bones, protecting against stress from eversion.
anterior talofibular ligament
most at risk for injury from ankle inversions
extra-articular structure of the ankle
Great toe abnormally abducted
Focal heel pain on palpation of the plantar fascia.
Plantar Flexion of the ankle
gastrocnemius, soleus, plantaris, tibialis posterior
tibialis anterior, extensor digitorum longu, extensor hallucis longus
tibialis posterior and anterior
Peroneus longus and brevis
Peroneal tendon instability test
active test that seeks to reproduce sublaxation or dislocation of the peronial tendons anterior to the lateral malleolus
Can you still have plantar flexion with a ruptured achilles tendon?
Distal radius fracture with volar apex angulation
Occurs when you fall with an outstretched hand.
4 things to look for on a Hip Radiograph
Joint space, fractures, acetabulum, femoral neck, dislocations.
ottawa knee rules
Pt is >55 y/o, inability to bear weight both immediately and in the emergency department (4 steps), isolated tenderness of the patella, tenderness at head of fibula, inability to flex to 90 degrees.