Neuromusculoskeletal Examination and Assessment A ... - (PG 86 - 98) PDF

Physical examination CHAPTER 3
Neurological tests Reduced sensory input

Sensory changes are due to compression or lesion of
Neurological examination includes neurological the sensory nerves anywhere from terminal branches
integrity testing (the ability of the nervous system in the receptor organ, e.g. joints, skin, to the spinal
to conduct an action potential), neurodynamic tests nerve root. Figure 3.15 serves to illustrate this.
(the ability of the nervous system to move) and the Knowledge of the cutaneous distribution of nerve
sensitivity of the nerves to palpation. roots (dermatomes) and peripheral nerves enables
the clinician to distinguish the sensory loss due to
Integrity of the nervous system a root lesion from that due to a peripheral nerve
The effects of compression of the peripheral nervous lesion. The cutaneous nerve distribution and derma-
system are: tome areas are shown in Figures 3.16–3.19. It must
be remembered, however, that there is a great deal
• reduced sensory input
of variability from person to person and an overlap
• reduced motor impulses along the nerve between the cutaneous supply of peripheral nerves
• reflex changes (Walton 1989) and dermatome areas (Hockaday &
• pain, usually in the myotome or dermatome Whitty 1967). A sclerotome is the region of bone
distribution supplied by one nerve root; the areas are shown
• autonomic disturbance such as hyperaesthesia, in Figure 3.20 (Inman & Saunders 1944; Grieve
paraesthesia or altered vasomotor tone. 1981).
Dorsal scapular nerve

From C4
To phrenic nerve C5
Suprascular nerve To scaleni
Nerve to subclavius C6
To scaleni
Lateral pectoral nerve
C7
Lateral cord To scaleni
Copyright © 2011. Elsevier Health Sciences. All rights reserved.
Long thoracic nerve

Posterior cord C8
Musculocutaneous nerve To scaleni
T1
Axillary nerve
From T2
Radial nerve
First intercostal nerve
Median nerve Medial pectoral nerve
Ulnar nerve Upper subscapular nerve
Medial cutaneous Medial cord

nerve of forearm Thoracodorsal nerve
Medial
cutaneous Lower subscapular nerve
nerve of arm
Figure 3.15 • A plan of the brachial plexus showing the nerve roots and the formation of the peripheral nerves. (From
Williams et al. 1995, with permission.)
Neuromusculoskeletal Examination and Assessment : A Handbook for Therapists, edited by Nicola J. Petty, Elsevier Health Sciences, 2011. ProQuest Ebook 67
Central, http://ebookcentral.proquest.com/lib/mqu/detail.action?docID=1721329.
Created from mqu on 2020-03-11 00:38:03.
Neuromusculoskeletal Examination and Assessment
Figure 3.16 • A Cutaneous nerve

supply to the face, head and neck.
Ophthalmic (From Williams et al. 1995, with
Greater permission.) B Dermatomes of the head
occipital
C2, 3 and neck. (From Grieve 1981, with
permission.)
Lesser
occipital C2
Maxillary
Greater
auricular C2, 3
Mandibular
Dorsal rami
of C3, 4, 5
Transverse
cutaneous of
neck, C2, 3
A
Supraclavicular
C3, 4
Fifth
cranial
nerve C2
C3
C4
B
Reduced motor impulses along the nerve (myotomes) and peripheral nerves enables the
A loss of muscle strength is indicative of either a clinician to distinguish the motor loss due to a root
lesion of the motor nerve supply to the muscle(s) – lesion from that due to a peripheral nerve lesion.
located anywhere from the spinal cord to its The peripheral nerve distribution and myotomes
terminal branches in the muscle – or a lesion of are shown in Table 3.9 and Figures 3.21–3.23.
the muscle itself. If the lesion occurs at nerve root It should be noted that most muscles in
level then all the muscles supplied by the nerve root the limbs are innervated by more than one nerve root
(the myotome) will be affected. If the lesion occurs (myotome) and that the predominant segmental
in a peripheral nerve then the muscles that origin is given.
it supplies will be affected. A working knowledge Over a period of time of motor nerve impairment
of the muscular distribution of nerve roots there will be muscle atrophy and weakness, as is seen
68 Examination and Assessment : A Handbook for Therapists, edited by Nicola J. Petty, Elsevier Health Sciences, 2011. ProQuest Ebook
Neuromusculoskeletal
for example in the thenar eminence in carpal tunnel Testing sensation

syndrome (median nerve entrapment). There are five aspects of sensation that can be
examined:
Reflex changes
1. light touch
The deep tendon reflexes test the integrity of the 2. vibration: tests posterior-column large-diameter
spinal reflex arc consisting of an afferent or sensory fibre patency
neurone and an efferent or motor neurone. The reflexes
3. joint position sense
test individual nerve roots, as shown in Table 3.9.
Procedure for examining the integrity of the ner- 4. pinprick: tests spinothalamic small diameter
vous system. In order to examine the integrity of the 5. temperature fibre patency (Fuller 2004).
peripheral nerves, three tests are carried out: skin Loss of light touch is usually examined first. It is
sensation, muscle strength and deep tendon reflexes. important that any diminished skin sensation is iden-
If a nerve root lesion is suspected, the tests carried tified accurately and sensitively by the clinician. Cot-
out are referred to as dermatomal (area of skin ton wool is often used to test the ability to feel light
supplied by one nerve root), myotomal (group of touch. The clinician strokes an unaffected area of the
muscles supplied by one nerve root) and reflexal. skin first so that the patient knows what to expect.
Supraclavicular nerves
T2
3
4 T3
4
5 5
T2
6 6
Anterior cutaneous
branches of 7 7
thoracic nerves Lateral cutaneous
8 8 branches of thoracic nerves
9
9 10
T1
10 11
11
Lateral cutaneous
12 branches of twelfth thoracic
Anterior cutaneous branch nerve
of iliohypogastric nerve
L1
Lateral femoral cutaneous
Ilio-inguinal nerve nerve
Femoral branch of genitofemoral

nerve
A
Figure 3.17 • A Cutaneous nerve supply to the trunk. (From Williams et al. 1995, with permission.)
(Continued)
Supraclavicular nerves
T2 T2
T3
T3
T4
T4
T5
Xiphoid process T5
T2 T6 T6
T7 T7
T8 Costal margin
T8
T1 T9 T9
T10 Umbilicus T10
T11 T11
Anterior superior iliac spine
T12 T12
Inguinal ligament
Pubic tubercles
B C
Figure 3.17—cont’d • B Anterior view of thoracic dermatomes associated with thoracic spinal nerves. C Lateral view of
dermatomes associated with thoracic spinal nerves. (From Drake et al. 2005.)
The clinician then lightly strokes across the skin of the Areas of sensory abnormality should be documen-
area being assessed and the patient is asked whether it ted on the body chart. Mapping out an area needs to
feels the same as or different from the other side. An be accurate, as a change, particularly an increase in
alternativeandmorestandardisedmethodofassessment the area, indicates a worsening neurological state
of light touch to deep pressure is to use monofilaments and may require the patient to be referred to a med-
(Semmes–Weinstein or West). Each monofilament ical practitioner; for example, progressive signs due
relates to a degree of pressure, is repeatable and scales to a prolapsed intervertebral disc pressing on the spi-
from loss of protective sensation through diminished nal cord or cauda equina may require immediate sur-
light touch to normal sensation (Hunter 2002). gery. For this reason, sensation is often reassessed at
The clinician needs to identify and map out accu- each appointment, until it is established that the
rately the area of diminished sensation. The next step diminished sensation is stable.
may be to explore further the area of diminished sen-
sation, by testing pinprick (the ability to feel pain), Testing muscle strength
vibration sensation, hot/cold sensation, joint position Muscle strength testing consists of carrying out an iso-
sense (proprioception) and stereognosis (in the metric contraction of a muscle group over a few seconds.
hand). Vibration sense can be tested using a 128-Hz The muscle is placed in mid-position and the patient is
(some researchers advocate 256-Hz) tuning fork. asked to hold the position against the resistance of the
With the patient’s eyes closed the clinician strikes clinician. The resistance is applied slowly and smoothly
the fork before placing the flat end of the tuning fork to enable the patient to give the necessary resistance,
on a bony prominence, e.g. medial malleolus. The and the amount of force applied must be appropriate
patient is asked to confirm when s/he feels vibration to the specific muscle group and to the patient.
(Leak 1998; Fuller 2004). Myotome testing is shown in Figures 3.24 and 3.25.
C3 C3
C4
C4
C5
C5
T2
T2
C5
T1
T1
T1
C6
C8 C8
C7 C6 C7
C8 C7
A
Anterior Posterior
Radial nerve Radial nerve

Posterior cutaneous Posterior cutaneous
nerve of arm nerve of arm
T2 T2
Musculocutaneous nerve Musculocutaneous nerve

Lateral cutaneous Lateral cutaneous
nerve of forearm nerve of forearm
T1 T1
Radial nerve
superficial branch
Radial nerve
superficial branch
Ulnar nerve Ulnar nerve
Median
nerve
Median nerve
B
Figure 3.18 • Dermatomes and nerves of the upper limb. Dots indicate areas of minimal overlap. (From Drake et al. 2005.)
L1 L2
L1 S3
S4
L2 L2
L3
S2
L3
L3
S2
L4 L4
L5
L5
S1 S1
L5
L4 S1
L4
A L5
Posterior rami (L1 to L3)
Posterior rami (S1 to S3)

Lateral cutaneous
nerve of thigh
(from lumbar plexus)
Obturator nerve
Femoral nerve (medial and Posterior cutaneous Obturator nerve

intermediate nerves of thigh) nerve of thigh
(from sacral plexus)
Common fibular nerve Femoral nerve (saphenous nerve)

Femoral nerve (lateral cutaneous of calf)
(saphenous nerve)
Common fibular nerve Tibial nerve (sural nerve)

(superficial branch)
Tibial nerve
Common fibular nerve (medial calcaneal branches)
(deep branch)
B
Figure 3.19 • Dermatomesandmajor nervesof thelowerlimb. Dots indicate areas ofminimaloverlap. (From Drakeet al. 2005.)
Neuromusculoskeletal Examination and Assessment : A Handbook for Therapists, edited by Nicola J. Petty, Elsevier Health Sciences, 2011. ProQuest Ebook
L2 L2
L3
C4 L3
L4
L5 S1 S1
C5
L4 L4
C5 L4
S1 L5
L5
C5 C6
C7 L2
C7
C6 L3 L3
C8
L4
L4
C7 L4
C7 L5 S1
L5
C6
C8
C6
S1
C8
S2
S2
C7
Anterior Posterior Anterior Posterior

Figure 3.20 • Sclerotomes of the upper and lower limbs. (From Grieve 1991, with permission.)
If a peripheral nerve lesion is suspected, the clinician exaggerated reflex response suggests an upper motor
may test the strength of individual muscles supplied lesion response, such as multiple sclerosis. Clonus is
by the nerve using the MRC scale, as mentioned earlier. associated with exaggerated reflexes and is charac-
Further details of peripheral nerve injuries are beyond terised by intermittent muscular contraction and
the scope of this text, but they can be found in standard relaxation produced by sustained stretching of a
orthopaedic and neurological textbooks. muscle. It is most commonly tested in the lower limb,
where the clinician sharply dorsiflexes the patient’s
Reflex testing foot with the knee extended. If an upper motor
The deep tendon reflexes are elicited by tapping the neurone lesion is suspected the plantar response
tendon a number of times. The commonly used deep should be tested. This involves stroking the lateral
tendon reflexes are the biceps brachii, triceps, patel- plantar aspect of the foot and observing the movement
lar and tendocalcaneus (Figure 3.26). of the toes. The normal response is for all the toes to
The reflex response may be graded as follows: plantarflex, while an abnormal response consists of
– or 0: absent dorsiflexion of the great toe and downward fanning
– or 1: diminished out of the remaining toes (Walton 1989), which is
known as the extensor or Babinski response.
þ or 2: average
Reflex changes alone, without sensory or motor
þþ or 3: exaggerated changes, do not necessarily indicate nerve root in-
þþþ or 4: clonus. volvement. Zygapophyseal joints injected with
A diminished reflex response can occur if there is a hypertonic saline can abolish ankle reflexes, which
lesion of the sensory and/or motor pathways. An can then be restored by a steroid injection (Mooney
Table 3.9 Myotomes (Grieve 1991)
Root Joint action Reflex

V cranial (trigeminal N) Clench teeth, note temporalis and masseter muscles Jaw
VII cranial (facial N) Wrinkle forehead, close eyes, purse lips, show teeth
XI cranial (accessory N) Shoulder girdle elevation and sternocleidomastoid
C1 Upper cervical flexion
C2 Upper cervical extension
C3 Cervical lateral flexion
C4 Shoulder girdle elevation
C5 Shoulder abduction Biceps jerk
C6 Elbow flexion Biceps jerk
C7 Elbow extension Triceps jerk and brachioradialis
C8 Thumb extension; finger flexion
T1 Finger abduction and adduction
T2–L1 No muscle test or reflex
L2 Hip flexion
L3 Knee extension Knee jerk
L4 Foot dorsiflexion Knee jerk
L5 Extension of the big toe
S1 Eversion of the foot Ankle jerk
Contract buttock
Knee flexion
S2 Knee flexion
Toe standing
S3–S4 Muscles of pelvic floor, bladder and genital function
& Robertson 1976). For this reason, reflex changes here, but further details of the theoretical aspects of
alone may not be a relevant clinical finding. It should these tests and how the tests are performed can be
also be realised that all tendon reflexes can be exag- found in Butler (2000) and Shacklock (2005). In
gerated by tension and anxiety. addition to the mobility tests described overleaf,
the clinician can also palpate the nerve with and with-
Neurodynamic tests out the nerve being under tension; details are given
The mobility of the nervous system is examined by under palpation in relevant chapters. The testing pro-
carrying out what are known as neurodynamic tests cedures follow the same format as those of joint
(Butler 2000). Some of these tests have been used by movement. Thus, resting symptoms are established
the medical profession for over 100 years (Dyck prior to any testing movement and then the following
1984), but they have been more fully developed information is noted:
by several therapists (Elvey 1985; Butler 2000; • the quality of movement
Maitland et al. 2001). A summary of the tests is given • the range of movement
Axillary nerve
Deltoid
Triceps long head
Triceps lateral head Teres minor
Triceps
medial head
Radial nerve
Brachioradialis
Coracobrachialis
Musculocutaneous nerve Extensor carpi radialis longus
Extensor carpi radialis brevis
Supinator
Biceps Posterior interosseous
Extensor carpi ulnaris
nerve
Extensor digitorum
Extensor digiti minimi
Abductor pollicis longus
Extensor pollicis longus
Extensor pollicis brevis
Brachialis
Extensor indicis
B
A
Figure 3.21 • The musculocutaneous (A), axillary and radial (B) nerves of the upper limb and the muscles that each
supplies. (Medical Research Council 1976 Aids to the investigation of peripheral nerve injuries. HMSO, London.
Reproduced with kind permission of the Medical Research Council.)
• the resistance through the range and at the end of As with all examination techniques the tests selected
the range should be justified through sound clinical reasoning.
• painbehaviour(localandreferred)throughtherange. Patients are first informed what the purpose of
A test is considered positive if one or more of the the test is and to tell the clinician if they feel any
following are found: symptoms during the movement. Single movements
in one plane are then slowly added, gradually taking
• All or part of the patient’s symptoms have been the upper or lower limb through a sequence of
reproduced. movements. The order of the test movements will
• Symptoms different from the ‘normal’ response influence tissue response (Coppieters et al. 2006).
are produced. Taking up tension in the region of symptoms will test
• The range of movement in the symptomatic limb nerve tissue more specifically. For example, in a
is different from that of the other limb. chronic ankle sprain with a possible peroneal nerve
component, plantar flexion and inversion may be the test to be valid all other body parts are kept still.
moved first, adding in straight-leg raise with addi- The clinician may assume a positive test if a desen-
tional sensitisers at the hip afterwards. If a patient’s sitising movement eases the patient’s symptoms. For
symptoms are very irritable, then adding local com- example, for the patient in supine with hip flexion
ponents first may prove to be too provocative. What with knee extension when this produces posterior
matters is consistency in sequencing at each time of thigh pain, the clinician may then add cervical flexion
testing. Each movement is added on slowly and care- if the thigh pain is increased with cervical flexion.
fully and the clinician monitors the patient’s symp- This is a positive test and suggests a neurodynamic
toms continuously. If the patient’s symptoms are component to the thigh pain.
reproduced then the clinician moves a part of the Neurodynamic tests include the following:
spine, or limb that is far away from where the symp- • passive neck flexion
toms are, either to increase the overall length of the
• straight-leg raise
nervous system (sensitising movement), also known
as a tensioner technique, or to decrease the overall • prone knee bend
length of the nervous system (desensitising move- • femoral nerve slump test
ment) or to examine the nerve’s relationship with • saphenous nerve test
its interface and its ability to ‘slide’. In order for • slump
Median nerve
Pronator teres
Flexor carpi radialis

Palmaris longus
Anterior interosseous nerve
Flexor digitorum superficialis
Flexor digitorum profundus I & II
Flexor pollicis longus
Pronator quadratus
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis Second lumbrical
First lumbrical
A
Figure 3.22 • Diagram of the median (A).
(Continued)
Ulnar nerve
Flexor carpi ulnaris

Flexor digitorum
profundus III & IV
Adductor pollicis
Flexor pollicis brevis
Abductor
First dorsal interosseous Opponens Digiti minimi
First palmar interosseous Flexor
Fourth lumbrical
Third lumbrical
B
Figure 3.22—cont’d • ulnar (B) Ulnar nerves of the upper limb and the muscles that each supplies. (Medical Research
Council 1976 Aids to the investigation of peripheral nerve injuries. HMSO, London. Reproduced with kind permission of
the Medical Research Council.)
• obturator nerve test the patient’s symptoms are. The basic component
• upper-limb neurodynamic tests (ULNT 1, 2a, 2b movements of the straight-leg raise are hip adduc-
and 3). tion, hip medial rotation, hip flexion and knee exten-
Passive neck flexion sion (affecting sciatic nerve). The foot can be moved
In the supine position, the head is flexed passively by the into any position, but ankle dorsiflexion/forefoot
clinician (Figure 3.27). The normal response would be eversion would sensitise the tibial nerve and ankle
painfree full-range movement. Sensitising tests include plantarflexion/forefoot inversion, the common pero-
the straight-leg raise or one of the upper-limb tension neal nerve. Additional movements of the forefoot
tests. Where symptoms are related to cervical exten- may be used to bias the medial and lateral plantar
sion, investigation of passive neck extension is necessary. nerves, which may be useful if symptoms are in the
Passively flexing the neck produces movement and ten- foot (Alshami et al. 2008). Neck flexion can be used
sion of the spinal cord and meninges of the lumbar spine to affect the spinal cord, meninges and sciatic nerve,
and of the sciatic nerve (Breig 1978; Tencer et al. 1985). and/or trunk lateral flexion to lengthen the spinal cord
and sympathetic trunk on the contralateral side.
Straight-leg raise The straight-leg raise moves and tensions the ner-
The patient lies supine. The way in which the vous system (including the sympathetic trunk) from
straight-leg raise is carried out depends on where the foot to the brain (Breig 1978). The normal
Iliacus
Femoral nerve Psoas

Obturator nerve
Adductor brevis
Rectus femoris Adductor longus

Quadriceps Vastus lateralis
femoris Gracilis
Vastus intermedius
Vastus medialis Adductor magnus
Common peroneal nerve

Deep peroneal nerve
Superficial peroneal nerve
Peroneus longus Tibialis anterior
Extensor digitorum longus
Peroneus brevis
Extensor hallucis longus
Peroneus tertius
Extensor digitorum brevis
A
Figure 3.23 • Diagram of the nerves on the anterior (A) and
(Continued)
response to hip flexion/adduction/medial rotation Femoral nerve slump test

with knee extension and foot dorsiflexion would The femoral nerve can be more selectively tested
be a strong stretching feeling or tingling in the poste- with the patient in side-lying with the head and trunk
rior thigh, posterior knee and posterior calf and foot flexed, allowing cervical extension to be used as a
(Miller 1987; Slater 1994). Normal range of straight- desensitising test (Figure 3.29). The test movements
leg raise can vary between 56 and 115 hip flexion are as follows:
(Sweetham et al. 1974); however the clinician iden- • The clinician determines any resting symptoms
tifies what is normal for a patient by comparing both and asks the patient to say immediately if any of
limbs (Figure 3.28). the symptoms are provoked during any of the
Prone knee bend movements.
Traditionally, this test is carried out in the prone • The patient is placed in side-lying with the
position, as the name suggests, with the test being symptomatic side uppermost with a pillow under
considered positive if, on passive knee flexion, symp- the head (to avoid lateral flexion/rotation of the
toms are reproduced. This does not, however, differ- cervical spine). The patient is asked to hug both
entiate between nervous tissue (femoral nerve) and knees up on to the chest.
the hip flexor muscles, which are also being • The patient releases the uppermost knee to the
stretched. Normal range is between 110 and 150 clinician, who flexes the knee and then passively
with both limbs being compared. extends the hip, making sure the pelvis and trunk
Gluteus medius The clinician then passively adds lateral rotation of

Superior gluteal nerve Gluteus minimus the hip, dorsiflexion and inversion of the foot
Piriformis (Figure 3.30A). Shacklock (2005) suggests internal
Tensor fasciae latae
rotation of the hip because of the position of the sar-
Inferior glueal nerve torius muscle but advocates trying different posi-
Gluteus maximus
tions. Butler (2000) suggests external rotation of
Sciatic nerve
the hip based on a study of saphenous nerve entrap-
ments in adolescents (Nir-Paz et al. 1999). The cli-
Semitendinosus nician can sensitise the test by, for example, moving
Biceps long head the foot into plantarflexion if symptoms are above
Semimembranosus Biceps short head the knee (Figure 3.30B) or by moving the hip into
medial rotation if symptoms are below the knee,
Adductor magnus or by contralateral side flexion of the spine.
Tibial nerve Slump
Common peroneal nerve
This test is fully described by Maitland et al. (2001)
Gastrocnemius
medial head and Butler (2000) and is shown in Figure 3.31. The
Gastrocnemius slump test can be carried out as follows:
Soleus lateral head
• The clinician establishes the patient’s resting
Tibialis posterior symptoms and asks the patient to say immediately
Flexor digitorum longus Flexor hallucis longus if any of the symptoms are provoked.
• The patient sits with thighs fully supported
at the edge of the plinth with hands behind
the back.
Medial plantar nerve to
• The patient is asked to flex the trunk by ‘slumping
Lateral plantar nerve to the shoulders towards the groin’.
Abductor hallucis Abductor digiti minimi
Flexor digitorum brevis Flexor digiti minimi • The clinician monitors trunk flexion.
Flexor hallucis brevis Adductor hallucis
Interossei • Active cervical flexion is carried out.
• The clinician monitors cervical flexion.
B
• Active knee extension is carried out on the
asymptomatic side
Figure 3.23—cont’d • posterior (B) aspects of the lower
• Active foot dorsiflexion is carried out on the
limb and the muscles that they supply. (Medical Research
asymptomatic side
Council 1976 Aids to the investigation of peripheral nerve
• Return the foot and knee back to neutral.
injuries. HMSO, London. Reproduced with kind permission

of the Medical Research Council.) • Active knee extension is carried out on the
symptomatic side.
remainstill.Theclinicianmayneedtoaddhipmedial • Active foot dorsiflexion is carried out on the
or lateral rotation and/or hip abduction/adduction symptomatic side.
movement to produce the patient’s symptoms. • Return the foot and knee back to neutral.
• At the point at which symptoms occur the patient • Active bilateral foot dorsiflexion is carried out.
is then asked to extend the head and neck while
• Active bilateral knee extension is carried out.
the clinician maintains the trunk and leg position.
A typical positive test would be for the cervical • Return the foot and knee back to neutral.
extension to ease the patient’s anterior thigh pain Now thatallthecombinations of lower-limbmovements
and for the clinician then to be able to extend the have been explored, the clinician chooses the most
hip further into range. However, if cervical appropriate movement to which to add a sensitising
extension increases the patient’s anterior thigh movement. This would commonly be as follows:
pain, this is also a positive test. • Active knee extension on the symptomatic side is
Saphenous nerve test carried out.
The patient lies prone and the hip is placed in • Active foot dorsiflexion on the symptomatic side
extension and abduction with the knee extended. is carried out.

Neuromusculoskeletal Examination and Assessment A ... - (PG 86 - 98) PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Neuromusculoskeletal Examination and Assessment A ... - (PG 86 - 98) PDF

Uploaded by

Copyright:

Available Formats

Physical examination CHAPTER 3

Neurological tests Reduced sensory input

Dorsal scapular nerve

Suprascular nerve To scaleni

Long thoracic nerve

Ulnar nerve Upper subscapular nerve

Medial cutaneous Medial cord

Figure 3.16 • A Cutaneous nerve

for example in the thenar eminence in carpal tunnel Testing sensation

Femoral branch of genitofemoral

Radial nerve Radial nerve

Musculocutaneous nerve Musculocutaneous nerve

Posterior rami (L1 to L3)

Posterior rami (S1 to S3)

Femoral nerve (medial and Posterior cutaneous Obturator nerve

Common fibular nerve Femoral nerve (saphenous nerve)

Common fibular nerve Tibial nerve (sural nerve)

Anterior Posterior Anterior Posterior

Table 3.9 Myotomes (Grieve 1991)

Root Joint action Reflex

S3–S4 Muscles of pelvic floor, bladder and genital function

Triceps long head

Triceps lateral head Teres minor

Musculocutaneous nerve Extensor carpi radialis longus

Extensor carpi radialis brevis

Flexor carpi radialis

Flexor carpi ulnaris

Femoral nerve Psoas

Rectus femoris Adductor longus

Common peroneal nerve

Extensor digitorum brevis

response to hip flexion/adduction/medial rotation Femoral nerve slump test

Gluteus medius The clinician then passively adds lateral rotation of

injuries. HMSO, London. Reproduced with kind permission

You might also like