Abstract
This chapter highlights the importance of a systematic, targeted, physical examination in the evaluation of patients with pain and describes each of the components in detail. General observations are made as soon as the practitioner encounters the patient and are followed by an assessment of their mental status before delving into the musculoskeletal portion of the examination. This includes inspection, palpation, and range-of-motion testing. Next the neurologic portion of the examination is performed and involves strength, sensation, and reflex testing. Finally targeted provocative maneuvers are performed before integrating the findings in the context of the history to generate a differential diagnosis.
Keywords
gait, physical exam, provocative tests, range of motion, reflexes, sensation, special tests, strength
The physical examination of a patient with pain is the most significant diagnostic tool, surpassed in importance only by the pain history. The goals of the physical examination include developing the patient’s trust, gaining insight into the impact of pain on the patient’s level of functioning, and ultimately identifying potential pain generators and other neuromusculoskeletal derangements. To simplify and focus what can be a complex physical examination, a logical and systematic approach should be followed ( Table 4.1 ). The pain physical examination is a comprehensive neuromusculoskeletal evaluation that begins with general observations and a mental status examination. This is followed by inspection; palpation; range-of-motion (ROM) evaluation; and testing of strength, sensation, and reflexes. Finally, provocative maneuvers of the affected body region(s) are performed. This chapter outlines each of these components in detail, but every joint or extremity need not be evaluated exhaustively. Instead, the nature of the patient’s complaint should be sufficiently established through history taking so that the physical examination can be efficiently directed toward the affected region.
| Examination | Observation |
|---|---|
| Inspection | Cutaneous landmarks, symmetry, temperature, trauma, muscle bulk |
| Palpation/percussion | Tenderness, masses, trigger points, pulses Tinel sign, fractures |
| Range of motion | Described in degrees, reason for motion limitation |
| Strength | Graded 0–5 |
| Sensation | Gain or loss of sensory function is tested and findings described in terms of dermatomal versus peripheral nerve distribution |
| Reflexes | Graded 0–4 |
| Provocative maneuvers | Performed for appropriate symptomatic region to further narrow differential diagnosis |
An in-depth knowledge and understanding of the examined region is vital to integrate the results of sensory, motor, and reflex examinations and come to a meaningful conclusion about the localization and nature of the lesion. The differential diagnosis established at the conclusion of the physical examination can be further narrowed through an appropriate diagnostic work-up.
General Observations
The physical examination should begin as soon as the patient walks into the office. Observations of the patient’s mannerisms, coordination, interpersonal interactions, and gait can provide insight into their mental, emotional, and physical status. Early observations in a less obvious setting (such as the waiting room) provide a basis against which to compare information collected during more formal portions of the examination. In particular, patients with chronic pain often display behaviors that communicate to others that they are experiencing pain and suffering, such as guarding, restlessness, audible sighs, altered gait, lack of eye contact, and use of unnecessary assistive devices. Any inconsistencies in gait or behavior should be noted.
Depending on practitioner preference and the magnitude of perceived impairment, evaluation of gait may be conducted informally as part of the general observation process or more formally during the motor portion of the neurologic examination. In general terms, gait is divided into two main phases: stance and swing. By definition, stance phase is the portion of the gait cycle during which the limb is in contact with the ground, and swing phase is the portion during which the limb has no points of contact with the ground. Although there are numerous detailed descriptions of normal and pathologic gaits, for a directed pain physical examination, the initial goal is to simply categorize the gait pattern as normal or abnormal. One specific type of abnormal gait that should be identified by the pain practitioner is antalgic gait, which is characterized by the avoidance of bearing weight on an affected limb or joint secondary to pain. This results in decreased time in stance phase for the affected limb. Other abnormal nonantalgic gait patterns may be caused by poor balance, neurologic deficits, or musculoskeletal disorders ( Box 4.1 ). Gait analysis should include observation of the width of the basis of support, stride length, cadence, and pelvic motion and tilt. Because most gait abnormalities are not specific for a particular pathology, further investigation is almost always indicated to detect the cause.
Antalgic gait —Avoidance of weight bearing on the affected limb due to pain (i.e., short stance phase). Seen in patients with radicular pain or painful lower extremity conditions, such as hip or knee osteoarthritis or other trauma to the affected limb.
Ataxic gait —Unsteady, uncoordinated ambulation, with a wide base and the feet thrown out, coming down first on the heel and then on the toes with a double tap.
Propulsive gait —Stooped, rigid posture with head/neck bent forward. Seen with Parkinson disease, CO poisoning, antipsychotics, such as haloperidol and chlorpromazine.
Scissoring gait —Crossing of the legs while advancing with slow, small steps. Seen with CVA, SCI, syringomyelia, MS, liver failure, cervical myelopathy, cerebral palsy.
Spastic gait —Indicates central lesion or head trauma.
Steppage gait —Caused by foot drop, so toes scrape the ground. Seen with lumbar HNP, peroneal atrophy, peroneal neuropathy or polyneuropathy, Guillain-Barré, MS, SCI, poliomyelitis.
Vaulting —Compensatory strategy to clear an advancing lower extremity that cannot be shortened, such as in the case of weak hip flexion, knee flexion, or ankle dorsiflexion that involves rising up on the toes of the stance limb so that the swing limb may clear the floor.
Circumduction —Swing limb is advanced in a semicircular arc to create extra clearance when the functional length of the advancing limb cannot be shortened in the usual fashion with hip flexion, knee flexion, or ankle dorsiflexion.
Waddling gait —Like a duck. Muscular dystrophy, gluteus medius weakness, spinal muscle atrophy, hip problems.
The general assessment should also include measurement of vital signs because they provide an objective indication of the patient’s general health status and, if abnormal (fever, uncontrolled hypertension), may be a relative contraindication to interventions.
Mental Status Examination
During history taking, it is key to develop trust and basic insight into cognition to determine how detailed of a mental status examination is warranted. A basic mental examination is described in Table 4.2 . Descriptors of the general mental status include the patient’s level of consciousness; alertness; orientation to person, place, and time; and demeanor toward the examiner. Signs of mental deterioration should correlate with the patient’s history or prompt a search for an underlying pathology. The examiner should be especially vigilant for signs of undiagnosed depression, which is frequently associated with chronic pain.
| Orientation to person, place, and date |
| Ability to name objects (e.g., pen, watch) |
| Memory immediate at 1 min, and at 5 min; repeat the names of three objects |
| Ability to calculate serial 7s, or if patient refuses have them spell “world” backward |
| Signs of cognitive deficits, aphasia |
Inspection
After completing general observations and the mental status examination, attention should turn to the neuromusculoskeletal examination. This begins with inspection of the affected region. Signs of trauma including erythema, swelling, bruising, peripheral joint effusion, or lacerations, as well as evidence of more remote trauma such as scarring should be noted in the affected body region. In addition, examiners should be mindful of evidence of rashes, infection, herpetic lesions, edema, sudomotor alterations, cutaneous discoloration, and abnormal hair growth. The identification of any surgical scars is also important, particularly in the cervical, thoracic, or lumbar spine, where their presence may indicate a history of spine surgery that is a relative contraindication for certain interventions. Inspection of muscular structures should focus on evaluation of bulk and symmetry and should identify any atrophy, hypertrophy, fasciculations, or masses that are present. Hypertrophy suggests overuse, whereas atrophy and fasciculations may indicate a lower motor neuron disorder. In addition to visual inspection, the cutaneous temperature should be measured peripherally in suspected cases of sympathetically maintained pain.
Inspection of the head and face should be performed similarly to other regions of the body and should always include the oral cavity because intraoral lesions that frequently refer pain to distant facial regions may be missed if only external structures are examined. Furthermore, any facial asymmetry should be noted and investigated in subsequent portions of the examination to better elucidate the underlying etiology.
When the cervical spine, shoulders, or upper back are the regions of suspected pathology, inspection should focus on identifying any postural abnormalities, such as a forward protruding head or protracted shoulders, that may be contributing to the patient’s symptoms, because these may be amenable to postural re-education in physical therapy. Similarly, when pathology is suspected in the low back, hips, or sacrum, any abnormal pelvic obliquity, tilt, or rotation should be identified. More distally, alignment at the hips, knees, and ankles should be evaluated for any varus or valgus deformities that place bony and soft tissue structures under abnormal stresses that may predispose to chronic conditions, such as osteoarthritis or tendinopathy. With regard to the spine, inspection should focus on establishing the presence of abnormal curvatures in the coronal and sagittal planes, such as increased kyphosis in the cervicothoracic region, accentuated or reduced lordosis in the lumbar region, and scoliosis in any region of the spine. For example, reduced lordosis or functional scoliosis may signify severe paraspinal muscle spasm, whereas exaggerated lumbar lordosis may indicate weakened abdominal musculature or a tethered cord. Usually, these curvatures can be identified and assessed by thorough inspection and palpation, except in the very obese.
In each region, the mechanical alterations that result from the observed abnormal curvature should be considered and interpreted in conjunction with information from the history to establish a differential diagnosis for the patient’s symptoms. In the thorax, the spine and rib cage essentially function as one unit to transmit loads and torque into the lumbosacral spine. Because loads are shared and there is not a great deal of mobility in this region, in the absence of trauma, surgery, and congenital defects, clinically significant thoracic degenerative changes are not very common. When observed, thoracic kyphosis or scoliosis is an important indicator of thoracic alignment and possible neural and intrathoracic compression. The lumbar spine is less restricted than the thoracic spine, and greater curvatures can be observed in this region.
Palpation
Palpation of superficial structures follows inspection and can help to further narrow the cause of the patient’s pain. Lymph nodes, discrete trigger points, and lipomas can look very similar, but with palpation each lesion can be distinguished. Tenderness to palpation over specific structures suggests that these entities are pain generators. For example, tenderness to palpation over the greater trochanter may be suggestive of trochanteric bursitis. Patients with allodynia, dysesthesia, hyperesthesia, or other sensory derangements often are unable to tolerate this portion of the examination. When tolerated, palpation should be performed in a systematic, comprehensive manner from the least to most painful area with standard pressure. This permits an appreciation of the normal tissues against which to compare the painful region. The objectives of palpation are to identify and delineate subcutaneous masses, edema, and muscle contractures; assess pulses; and to localize tender myofascial trigger points. Remember that unless the pain is bilateral, there is a contralateral structure that can be palpated and used as a control in most patients.
Percussion of specific structures also reveals useful information but, like palpation, is dependent on the patient being able to tolerate it. Pain on percussion of bony structures can indicate a fracture, abscess, or infection. Percussion of spinous processes is often performed to determine whether a vertebral body fracture is a true pain generator or an incidental magnetic resonance imaging (MRI) finding. Pain on percussion over a sensory nerve, or Tinel sign, can indicate nerve entrapment or the presence of a neuroma. Specific nerves commonly tested with this technique are discussed in the section on provocative maneuvers.
Facial palpation is important to identify masses or tenderness over the sinuses. The only major articulation in the face is the temporomandibular joint (TMJ), which can dislocate or freeze and should be palpated to detect any bony asymmetry when patients complain of pain or dysfunction in this region. A detailed facial examination should be performed in patients being evaluated for headache to identify referred pain patterns (supraorbital neuralgia, sinus headache, or headache secondary to TMJ syndrome).
Palpation in the cervical and trunk region can identify muscle spasms, myofascial trigger points, enlarged lymph nodes, occipital nerve entrapment, and pain over the bony posterior spine elements that suggests facet arthropathy. Upper extremity palpation should identify gross sensory changes and pulse symmetry.
Thoracic palpation should mainly focus on ruling out rib and spine fractures. Palpation of the abdominal wall may differentiate between superficial and deep pain generators. Deep palpation can detect pulsatile masses consistent with an abdominal aortic aneurysm that can present as low thoracic back pain.
Palpation in the lumbar spine begins with identification of the bony landmarks, specifically the iliac crests. The horizontal line connecting the iliac crests approximately estimates the L4–L5 level. Severe tenderness to midline palpation may be present with supraspinous or interspinous ligamentous rupture. Moreover, the location of tenderness may provide important clues as to the etiology of lumbar spine pain. For example, discogenic low back pain is nearly always associated with midline tenderness and in most cases paraspinal tenderness, whereby facetogenic pain is associated with paraspinal tenderness in a large majority of cases but is infrequently associated with prominent midline tenderness. In contrast, sacroiliac joint pain is predominantly associated with unilateral pain situated predominantly below L5. Common bony pain generators in the lumbar region include the facet joints, sacroiliac joints, and the coccyx. For piriformis syndrome or coccydynia, a digital rectal examination is a valuable tool for diagnosis. Soft tissue palpation is important to evaluate paraspinous muscle tone, the localization of trigger points, and the presence of masses or lipomas.
Range of Motion
ROM testing is important to help to identify soft tissue restrictions, functionally limiting deficits in ROM and hypermobility and laxity that may be a risk factor for specific injuries. Active ROM is that brought about by the patient’s own effort, whereas passive ROM is generated by the examiner moving a body part through its arc of motion. The possibilities of ROM depend on the body location or joint. For example, in the shoulder the movements include flexion, extension, abduction, adduction, and external and internal rotation. The ROM for each possible movement is described in terms of maximum degrees of movement through which the body part was moved either actively or passively and the reported reason for any limitations. Alternatively, when arcs are not formally measured it may be helpful to classify ROM as increased, full, or mildly, moderately, or severely restricted. It is important to be aware that ROM may also be greater than expected. Joint, connective tissue, or ligamentous laxity can result in supranormal ROM, whereas pain and structural abnormalities (strictures, arthritis) can limit ROM.
Tone, the sensation of resistance felt as one manipulates a joint through its expected ROM with the patient relaxed, is described in terms of hypotonia and hypertonia. Hypotonia, a decrease in the normal expected muscular resistance to passive manipulation, is due to a depression of alpha or gamma motor unit activity either centrally or peripherally. Hypotonia can be seen in polyneuropathy, myopathy, and certain spinal cord lesions. Hypertonia, a greater-than-expected normal resistance to passive joint manipulation, is divided into spasticity and rigidity. Spasticity is defined as a velocity-dependent increase in tone with joint movement. Spasticity is seen with excitation of spinal reflex arcs or with loss of descending inhibitory control in the reticulospinal or rubrospinal tracts. Spasticity is commonly seen after brain and spinal cord injury and stroke and in multiple sclerosis. It is commonly assessed using the Modified Ashworth Scale ( Table 4.3 ). Rigidity, a generalized increase in muscle tone, is characteristic of extrapyramidal diseases, and is due to lesions in the nigrostriatal system.
| Score | Clinical Finding |
|---|---|
| 0 | No increase in muscle tone |
| 1 | Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of range of motion when the affected part is moved in flexion or extension |
| 1+ | Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the range of movement. |
| 2 | More marked increase in muscle tone through most of the range of movement, but affected part(s) easily moved. |
| 3 | Considerable increase in muscle tone, passive movement difficult |
| 4 | Affected part(s) rigid in flexion or extension |
In the head, when testing the TMJ, it is important to note any crepitus during active or ROM testing. In the neck, normal cervical active ROMs are flexion of 0–60 degrees; extension of 0–25 degrees; bilateral lateral flexion of 0–25 degrees; and bilateral lateral rotation of 0–80 degrees. Any reduction in active ROM should be documented with the reported reason for limitation.
The normal lumbar spine ROMs are flexion of 0–90 degrees; extension of 0–30 degrees; bilateral lateral flexion of 0–25 degrees; and bilateral lateral rotation of 0–60 degrees. Chapter 24 provides a review of the possible causes of limitation of ROM and pain. In general, pain on flexion hints at a possible disc lesion, whereas pain on extension can indicate spinal stenosis, spondylosis, or a myofascial pain generator.
The remainder of the examination of the face, cervical, and lumbar regions is based on motor, sensory, and reflex examinations, which are best reviewed in an integrated manner. A directed examination of the face is largely based on cranial nerve testing, for which a detailed strategy is presented in Table 4.4 . Table 4.5 lists appropriate tests for the C4–T1 nerve roots and Table 4.6 provides an outline for the L2–S1 roots.
| Cranial Nerve | Function | Test |
|---|---|---|
| I. Olfactory | Smell | Use coffee, mint, etc. held to each nostril separately; consider basal frontal tumor in unilateral dysfunction |
| II. Optic | Vision | Assess optic disc, visual acuity; name number of fingers in central and peripheral quadrants; direct and consensual pupil reflex; note Marcus-Gunn pupil (paradoxically dilating pupil) |
| III, IV, and VI. Oculomotor, trochlear, and abducens | Extraocular muscles | Pupil size; visually track objects in eight cardinal directions (abduction, abduction/elevation, elevation, adduction/elevation, adduction, adduction/depression, depression, abduction/depression); note diplopia (greatest on side of lesion); accommodation; note Horner pupil (miosis, ptosis, anhidrosis) |
| V. Trigeminal: motor and sensory | Facial sensation, muscles of mastication | Cotton-tipped swab/pinprick to all three branches; recall bilateral forehead innervation (peripheral lesion spares forehead, central lesion affects forehead); note atrophy, jaw deviation to side of lesion |
| VII. Facial | Muscles of facial expression | Wrinkle forehead, close eyes tightly, smile, purse lips, puff cheeks; corneal reflex |
| VIII. Vestibulocochlear (acoustic) | Hearing, equilibrium | Use tuning fork, compare side to side; Rinne test for AC versus BC (BC > AC); Weber test for sensorineural hearing |
| IX. Glossopharyngeal | Palate elevation; taste to posterior third of tongue; sensation to posterior tongue, pharynx, middle ear, and dura | Palate elevates away from the lesion; check gag reflex |
| X. Vagus | Muscles of pharynx, larynx | Check for vocal cord paralysis, hoarse or nasal voice |
| XI. Spinal accessory | Muscles of larynx, sternocleidomastoid, trapezius | Shoulder shrug, sternocleidomastoid strength |
| XII. Hypoglossal | Intrinsic tongue muscles | Protrusion of tongue; deviates toward lesion |
| Root Level | Nerve | Muscle(s) Tested | Position | Movement | Sensory | Reflex |
|---|---|---|---|---|---|---|
| C4 | Dorsal scapular | Levator scapulae | Sitting | Shrug shoulder | Shoulders | None |
| C5 | Musculocutaneous (C5–6) | Biceps | Forearm fully supinated, elbow flexed 90° | Patient attempts further flexion against resistance | Lateral forearm, first and second finger | Biceps |
| C6 | Radial (C5–6) | Extensor carpi, radialis, longus, and brevis | Elbow flexed at 45°, wrist extended | Maintain extension against resistance | Middle finger | Brachioradialis |
| C7 | Radial (C6–8) | Triceps | Shoulder slightly abducted, elbow slightly flexed | Extend forearm against resistance | Middle finger | Triceps |
| C8 | Anterior interosseous (median) (C7–8) | Flexor digitorum profundus | Finger extended at MCP and PIP, flexed at DIP | Maintain flexion at DIP against resistance | Fourth, fifth finger; medial forearm | None |
| T1 | Ulnar, deep branch (C8–T1) | Dorsal interossei | Patient extends and spreads all fingers | Examiner pushes patient’s fingers together, patient resists | Medial arm | None |
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