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Orthopedic Review Evaluation of Spine and Extremities
James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic
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Definition of an orthopedic test
Most often, a provocative maneuver that involves stretching, compressing and/or contracting of tissues in order to replicate the pain and identify the affected tissues.
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History Taking Process
Develop rapport HPI OPQRST Past history Review of Systems Patient expectations
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History of Present Illness
Observation is a continual process that begins with introduction
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Clarify Area of Chief Concern
Patient points to area of chief concern
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Clarify Pain Generators
Immediately following the positive finger point by the patient, palpate the tissue and determine the level and tissue involved with the chief concern
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History of Present Illness
Bakody’s Sign is present when placement of hand of involved upper extremity behind head reduces pain. Observed sign, not a test…
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History of Present Illness
Dejerine’s sign presents the reproduction of spinal pain with cough, sneeze or bowel movement. Test involves cough, sneeze, and BM…
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History of Present Illness
“Barre-Lieou Syndrome” is considered by many physicians to be synonymous with “Post Whiplash Type Injury”
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Symptoms that characterize Barré-Lieou syndrome
Headache, facial pain, ear pain, vertigo, tinnitus, loss of voice, hoarseness, neck pain, severe fatigue, muscle weakness, sinus congestion, a sense of the eyeball being pulled out, and numbness. Other symptoms may include a pins-and-needles sensation of the hands and forearms, corneal sensitivity, dental pain, lacrimation (tearing of the eyes), blurred vision, facial numbness, shoulder pain, swelling on one side of the face, nausea, vomiting and localized cyanosis of the face (bluish color).
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History of Present Illness
Rust Sign may be present… Post-traumatic Roll over Blow to skull
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History of “Roll Over” MVA
Rust sign may be present initially, which would indicate possible upper cervical spine instability or moderate to severe “whiplash type injury.” Past history of roll over MVA should raise suspicion of DDD,DJD, spondylosis, and stenosis in the cervical spine.
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History of Present Illness
Lhermitte Sign present with severe lancinating pain down spine and extremities most often with cervical flexion. SOL Multiple sclerosis
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Spine Evaluation Observation Palpation Range of motion
Special tests or Orthopedic tests
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Observation and Inspection
Gait Posture Appearance Appliances Deformities Contusions Cicatrices
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James J. Lehman, DC, MBA, DABCO
Valsalva Maneuver Valsalva maneuver for IVD syndrome or tumor (SOL) Increased intrathecal pressure Reproduce spinal and or radicular symptoms James J. Lehman, DC, MBA, DABCO
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Shoulder Abduction Test
Abduction of shoulder relieves the cervicobrachial symptoms revealing the presence of Bakody sign Indicates nerve root irritation James J. Lehman, DC, MBA, DABCO
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James J. Lehman, DC, MBA, DABCO
Swallowing Test Difficulty swallowing might be related to a space occupying lesion anterior to the cervical spine. Bleed, DISH, or SOL impede swallowing James J. Lehman, DC, MBA, DABCO
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Palpation Flat finger and static
Osseous Soft tissues Myofascial Neural Ligamentous Vascular Dermal
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Range of Motion and O’Donoghue’s Maneuver
Differentiates joint sprain/strain injuries Pain upon ROM Active = non-specific Passive = ligament Resistive = muscle
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Common Cervical Provocative Tests
All of them test for dural sheath, nerve root, or spinal nerve involvement Positive neurological findings all indicate radicular pain James J. Lehman, DC, MBA, DABCO
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Cervical Compression Tests
Active maximal foraminal compression Pain maybe indicate joint, muscle, or ligament pathology
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Cervical Compression Tests
Maximal foraminal compression (active) Jackson’s (acute) Spurling’s (in favor) Maximal foraminal compression(passive) Extension/Flexion (disc/joint) James J. Lehman, DC, MBA, DABCO
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Cervical Compression Tests
Passive foraminal compression Neutral Flexion/Extension Lateral flexion Rotation Jackson Spurling
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Cervical Distraction Test
Distraction test for nerve root, facet, or myospasm Positive test relieves pain Negative test increases pain James J. Lehman, DC, MBA, DABCO
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James J. Lehman, DC, MBA, DABCO
Soto-Hall Test Non-specific test for cervical spine injury or lesion Passive flexion of neck with sternum stabilized Relative contraindication with severe injury James J. Lehman, DC, MBA, DABCO
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Shoulder Depression Contralateral pain with radiations into upper extremity (nerve compression) Localized contralateral pain (joint compression) Ipsilateral radiating pain (nerve stretch)
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Brachial Plexopathy Thoracic Outlet Syndrome
90% of TOS are neurogenic conditions Post traumatic whiplash type injuries to scalene muscles
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Brachial Plexopathy TOS
Palpate Erb’s point and attempt to elicit brachial plexus symptoms. Compare affected and unaffected sides
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Brachial Plexopathy TOS
Perform Cervical ROM testing Compression test Shoulder depression TOS tests
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Thoracic Outlet Syndrome
Thoracic outlet syndrome gets its name from the space (the thoracic outlet) between the clavicle and the first rib
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Thoracic Outlet Syndrome Special Tests
Roos Brachial plexus stretch Brachial plexus tension Adson’s Test Allen Wright
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Thoracic Outlet Tests Roos
2-3 minutes of hand flexion/extension with shoulders abducted and elbows flexed. Positive test = inability to complete test due to pain/heaviness.
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Vascular or Neurogenic Tests
Adson (vascular) Brachial plexus stretch (neurogenic)
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Thoracic Outlet Syndrome Wright’s Test
Hyperabduct and externally rotate the patient’s arm while assessing the ipsilateral radial pulse. Considered positive if the pulse diminishes or paresthesias develop (Safran, 2004).
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Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesias, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds. J Vasc Surg Sep;46(3):601-4.
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Brachial Plexopathy A burner is a nerve injury resulting from trauma to the neck and shoulder. Its primary symptom is burning pain radiating down one upper extremity.
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A "burner" is a common nerve injury resulting from trauma to the neck and shoulder, usually during sports participation. The injury is most often caused by traction or compression of the upper trunk of the brachial plexus or the fifth or sixth cervical nerve roots. Burners are typically transient, but they can cause prolonged weakness resulting in time loss from athletic participation. Furthermore, they often recur. Treatment consists of restoring range of motion, improving strength and providing protective equipment. Return to sports participation depends primarily on reestablishment of pain-free motion and full recovery of strength and functional status. (Am Fam Physician 1999;60: )
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The "Burner": A Common Nerve Injury in Contact Sports
Burners are typically Grade 1 or Grade 2 peripheral nerve injuries Neuropraxia Axonotmesis
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Mechanisms of "burners." Traction
Direct blow to the supraclavicular fossa at Erb's point Compression of the cervical roots or brachial plexus
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Spurling's test The test is positive if axial loading by the examiner's hands reproduces symptoms
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Muscle Innervation Clinical test Deltoid Axillary (C5, C6) Shoulder abduction Supraspinatus Suprascapular (C5, C6) "Full can" abduction* Infraspinatus External rotation Biceps brachii Musculocutaneous (C5, C6) Elbow flexion Pronator teres Median (C6, C7) Forearm pronation Triceps brachii Radial (C7, C8) Elbow extension Abductor digiti minimi Ulnar (C8, T1) Fifth digit abduction
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James J. Lehman, DC, MBA, DABCO
Neuropraxia This is a transient lesion (compression of neuron) and recovery is spontaneous within a few days or weeks. James J. Lehman, DC, MBA, DABCO
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Axonotmesis This lesion is due to compression or direct force.
Sensory loss is common. Prognosis for recovery is good. Occasionally, the loss of some cell bodies inhibits complete recovery.
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Axioms in Thoracic Spine Assessment
The thoracic spine requires evaluation in isolation and together with the cervical and lumbar spine
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Scheplemann Sign Intercostal Pain
Contralateral pain might indicate pleurisy or intercostal strain Ipsilateral pain might indicate intercostal neuropathy or costovertebral sprain
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Most Common Causes of Thoracic Pain
Zygapophyseal joints What would be your diagnosis?
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Intercostal Syndrome Differential Diagnosis
Intercostal neuralgia or neuritis Pleurisy Fractured rib Intercostal myofascial pain
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Scheurmann’s Disease Differentiation from Round Back
Spinal postural alterations do not resolve with recumbent position Confirmed with radiographic exam Sleeps with 2-3 pillows propped under back
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Sternal Compression Test Rib Fractures
Compresses lateral borders of ribs Fracture becomes more pronounced Produces or exacerbates fractured rib pain
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T-1 & T-2 Nerve Root Lesions
Scapular area pain with passive approximation of the scapulae Indicates T1 or T2 nerve root compression or irritation
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Hot Sponge Test Determine if the patient is experiencing an inflammatory condition with three to four strokes along spine.
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Myelopathy and Thoracic Disc Herniation Beevor’s Sign
When Beevor’s sign is present, T 7-12 spinal levels must be evaluated
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Ankylosing Spondylitis Mensuration of chest expansion
Normal expansion is 1.5 to 3” A decrease in normal expansion indicates restriction of movement at costotransverse or costovertebral joints
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Thoracic Scoliosis Origin of a lateral curvature of the spine
Idiopathic (85-90%) Congenital (Usually failure of formation) Neuromuscular
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Signs of Scoliosis How would you differentiate scoliosis from pelvic obliquity and postural imbalance? Adam’s position Leg length mensuration
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Sciatic Scoliosis Vanzetti Sign
Sciatica Level pelvis Scoliosis Suspect discopathy
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McKenzie Slide Glide Test
Test determines if scoliosis is related to back pain. Positive if the test increases the back pain.
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Serious Thoracic Disorders Myocardial infarct
Crushing pain radiating to the jaw or arm suggests acute ischemia or MI. Patients often ascribe myocardial ischemic pain to indigestion. Exertional pain relieved by rest indicates angina pectoris
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Lumbar Spine Back Pain Back pain is common from the second decade on.
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Lumbar Spine Scoliosis Postural imbalance Pelvic obliquity
Joint dysfunction DDD/DJD Myofascial condition Neural condition
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Characteristics of Low Back Pain Spinal Pain
Discogenic pain Nerve root pain Multiple levels of lumbar spinal stenosis
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Schober Test Mark lumbosacral junction, 10 cm superior, and 5 cm inferior Have patient flex forward and measure the differences
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Mensuration of Lumbar Flexion Schober Test
Normal findings would indicate 4 cm of increase with superior pair of marks and zero change with inferior pair of marks. Suspect AS or fusion with reduced movement
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Valsalva’s Maneuver Neuro-orthopedic application
Assessment for space-occupying lesion, tumor, intervertebral disc herniation, or osteophytes
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Lindner’s Sign Assessment for Lumbar Nerve Root Irritation
Passive flexion of neck with chin to chest Supine, seated, or standing position
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Lindner’s Sign Sign is present if procedure produces pain in lumbar spine with a radicular distribution
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Kemp Test May be performed in either a standing or sitting position
A positive test involves radicular pain
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Kemp’s Oblique bending toward symptomatic side increases pain with lesion lateral to nerve root Oblique bending away from symptomatic side increases pain with lesion medial to nerve root
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Kemp Maneuver Assessment
Intervertebral nerve root encroachment Muscular strain Ligamentous sprain Pericapsular inflammation
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Straight Leg Raise Test Nerve Root Tension Signs
Pain reaction 0-35 = extradural 35-70 = disc lesion 70-90 = lumbosacral lesion Dull pain in posterior thigh = hamstrings
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Straight-Leg-Raising Test
Dynamics: 0-35 degrees = no dural movement 35-70 degrees = tension of sciatic nerve over intervertebral disc Above 70 degrees presents very little additional deformation of nerve root
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Straight-Leg-Raising Test
Bilateral SLR testing Simultaneously perform Well-Leg-Raising test
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Straight-Leg-Raising Test
Assessment for space-occupying mass in the path of a nerve root, sacroiliac inflammation and lumbosacral involvement
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Well-Leg-Raising Test Fajersztajn’s Test
Assessment for lumbar nerve root lesion caused by IVD syndrome or dural sleeve adhesion Contralateral LE SLR
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Bragard Sign Nerve root tension sign
Assessment for radicular symptoms, intervertebral disc lesions, and sciatic neuropraxia. Follows SLR or Lasegue sign
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Sicard Sign Nerve root tension sign
SLR with dorsiflexion of large toe
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Turyn Sign Nerve root tension sign
Supine position Dorsiflexion of large toe without SLR Least provocative nerve root tension sign for sciatic nerve
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Minor’s Sign Painful or antalgic behavior due to protective myospasia
Crawling up thigh with listing while rising from a seated position
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Vanzetti's Sign The pelvis is always horizontal in spite of sciatica and scoliosis. In other lesions with scoliosis the pelvis is inclined. (pelvic obliquity)
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Antalgic Lean Sign “Antalgia Sign”
Painful discopathy causes listing in order to reduce mechanical nerve root pain.
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Antalgic Lean Sign Lateral disc protrusion produces a contralateral list Medial disc protrusion produces an ipsilateral list
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Differentiate Lateral Disc from Medial Disc Protrusion
Antalgic lean or antalgia sign Fajersztajn’s or Well Leg Test Kemp’s test
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Meyerding’s Classification of Spondylolisthesis
Grade 1 = 0-25% Grade 2 = 26-50% Grade 3 = % Grade 4 = 76%-100%
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Lumbar Central Canal Stenosis
Neurogenic claudication with pain upon walking Feel like legs are “giving way” Temperature changes and weakness in legs Night pain Sciatic tension signs are present
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Lateral Spinal Canal Recess Stenosis
Degenerative joint disease Encroachment of nerve root in canal Nerve root entrapment
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IVD or Space Occupying Lesion Milgram’s Test
Positive with either intrathecal or extrathecal pathology
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Milgram’s Test Assessment for IVD or Space-Occupying Lesion
Patient able to hold for 30 seconds rules out intrathecal pathology
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Positive Milgram’s Test
Indicates intrathecal or extrathecal pathology The test is positive if the patient experiences low back pain
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Differentiate Spinal Sprain/Strain
Describe your approach to differentiating sprain from strain of the lower back and pelvis
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SIJ Lesions Signs and Symptoms
SIJ pain Abnormal gait Palpation tenderness Pain on forward flexion Pain on sitting
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Hibb’s Test Differentiate Hip and SIJ Lesions
Prone leg to buttocks with lateral flexion and internal rotation Localized pain indicates either hip or SIJ pain
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Pelvic Rock Test Side posture downward pelvic compression
Pain in SIJ indicates lesion of inflammatory process
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Sign of the Buttock’s Supine SLR reveals unilateral restriction
Sign present with knee flexion but no increased hip flexion Sign indicates hip disease, such as trochanteric bursitis
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Absence of Sign of the Buttocks
Absence of sign when hip flexion increases upon knee flexion due to pain reduction Indicates lumbar dysfunction
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Flamingo Test Stand on one foot Hop to stress one joint
Tests SIJ, symphysis pubis, and hip
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Adam’s Supported Belt Test Differentiate Lumbar from SIJ Lesion
Lumbar pain with both supported and unsupported dorsolumbar flexion SIJ pain with unsupported flexion only
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Lewin-Gaenslen Test Side posture extension stresses SIJ & anterior SIJ ligaments Ipsilateral pain indicates a lesion in SIJ
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Yeoman’s Test Prone extension stresses SIJ & anterior SIJ ligaments
Ipsilateral pain indicates a lesion in SIJ
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SIJ Stretch Test Bilateral supine ASIS pressure
Pain indicates lesion in anterior SIJ ligaments or SIJ
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SIJ Resisted Abduction Test
Thigh or buttock pain indicates strain in TFL or gluteal muscles SIJ pain indicates sprain of SIJ ligaments
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Coccygodynia Myofascial pain is a common cause of coccygodynia
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Hip Palpation Point tenderness Edema Symmetry
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Hip Contracture Tests Thomas Test
Supine passive hip flexion Contralateral hip and knee flexion indicates a positive test for hip contracture Evaluate rectus femoris tightness
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Hip Contracture Tests Rectus Femoris Contracture Test
Involuntary extension of flexed knee with tightness in rectus femoris indicates a hip flexion contracture
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Hip Contracture Tests Piriformis Test
Piriformis pain with resisted abduction of hip indicates tight piriformis Sciatic pain indicates nerve compression
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Hip Contracture Tests Ely’s Heel to Buttocks
Prone heel to contralateral buttocks Ipsilateral pelvis rising from table indicates hip flexion contracture or tight rectus femoris
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Hip Contracture Tests Ober’s Test for TFL or ITB
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Ober’s Test Failure to descend smoothly indicates a positive test for contracture of the TFL or ITB.
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Trochanteric Bursitis
Palpation Patrick’s Positive finger point Laguerre’s
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Degenerative Hip Disease
Patrick’s Trendelenburg’s Scouring’s Laguerre’s Difficult to palpate
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Patrick’s Test FABERE & Figure of 4
Flexion Abduction External rotation
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Patrick’s Test Compresses femoral head into acetabulum
Positive test with pain in hip, which indicates an inflammatory process
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Pelvic Obliquity and Postural Imbalance
You must determine whether the leg length discrepancy is anatomical or functional
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Actual Leg-Length Test
This is a tape measurement that tests for anatomical leg length discrepancy. ASIS and medial malleolus are the landmarks identified
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Apparent Leg-Length Test
Reveals functional leg length discrepancy Umbillicus and medial malleolus are landmarks
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Functional Leg-Length Measurement
Measure length of both lower extremities supine and seated Inferior medial malloli are used as landmarks Read the body language
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Functional Leg-Length Measurement
Usually the ipsilateral malleolus will measure short when supine if the superior iliac crest appears inferior when standing and long when seated
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Trendelenburg’s Test Standing flexion of hip
Downgoing of contralateral hip is a positive test Indicates gluteal motor weakness and/or hip pathology of weight bearing LE
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Anvil Test Percussion of calcaneus compresses hip joint
Positive test with pain, which indicates fracture or hip pathology
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Congenital Hip Dysplasia DDH
Also known as Allis’ sign It is not used to evaluate functional leg length deficiency
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Evaluation of the Knee What type of injuries should we consider with our differential diagnosis of the knee?
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Osgood Schlatter’s Lesion
Anterior tubercle of tibia inflammation with young athletes who run and jump Fracture may occur with an acute injury
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Meniscus and Ligament Instability
Apley’s compression tests meniscus Apley’s distraction tests nonspecific ligaments
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Meniscal Injury McMurray’s Test
Flex and extend with internal and external rotation. Stresses distorted meniscus Palpable or audible click is positive
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Meniscal Injury Retreating McMurray
Palpate medial meniscus with knee and hip flexed 90 degrees plus lateral and medial rotation
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Meniscal Injury Retreating McMurray
Meniscal tear blocks medial rotation
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Meniscal Injury Bounce Home Test
Passive flexion of hip and knee Cup heel and request dropping of knee Femur rotation on tibia & extension blocked
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Meniscal Injury Bounce Home Test
Blockage or rubbery end feel with full extension are positive signs of meniscal injury
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Meniscal Injury Steinman’s Tenderness Test
Supine Hip and knee flexion to 90 degrees Palpate medial and lateral joint lines with index and thumb w/ flexion and extension
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Meniscal Injury Steinman’s Tenderness Test
Pain moving anteriorly with extension or posteriorly with flexion and indicates meniscal injury.
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Meniscal Injury Modified Helfet’s Test
Seated with foot on floor Note location of tibial tuberosity Extend leg and note location of tibial tuberosity
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Meniscal Injury Modified Helfet’s Test
Expect lateral movement of tibial tuberosity with extension of knee Blocked movement indicates meniscal injury
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Thessaly Test for Meniscus Tear
Five degree of knee flexion Unaffected knee first
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Thessaly Test for Meniscal Tear
External rotation assisted Internal rotation
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Thessaly Test for Meniscal Tear
Positive findings Repeat process at 20 degrees Pain medial or lateral Clicking or locking Most accurate at 20 degrees of knee flexion
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Ligament Instability Anterior and Posterior Drawer Signs
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Anterior Drawer Sign and Lachman’s Anterior Cruciate & Posterior Oblique
Anterior translation of more than 5 mm indicates injury
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Anterior Drawer Sign Anterior cruciate Medial collateral ligament ITB
Capsules & ligaments Arcuate-politeus complex
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Ligament Instability Lachman’s Test
Anterior and posterior cruciate ligament sprains Most reliable test for anterior cruciate ligament rupture
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Ligament Instability Slocum’s Test
Anterior cruciate Posteriorlateral capsule Fibular collateral ligament ITB
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Patellofemoral Dysfunction Patella Grinding Test
Chrondomalacia patellae Patellofemoral arthralgia Chondral fracture
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Patellofemoral Dysfunction Patella Apprehension Test
Pain and apprehension are present Positive test indicates lateral patellar dislocation
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Patellofemoral Dysfunction Dreyer’s Test
Patient cannot raise his leg while in a supine position
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Patellofemoral Dysfunction Dreyer’s Test
Stabilize quadriceps tendon and patient able to raise leg indicates traumatic fracture
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Patellofemoral Dysfunction Clarke’s Patellar Scrape Test
Pain and crepitation may indicate patellofemoral arthralgia or chondromalcia patellae
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Drawer’s Foot Sign Anterior drawer will be positive with gapping secondary to trauma Indicates sprain of anterior talofibular ligament
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Lateral Stability Test Talar Tilt Test
Sprain injury to calcaneofibular and/or anterior talofibular ligaments
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Ankle Examination
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Subtalar Examination
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High Ankle Sprain Mechanism
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High Ankle Sprain Syndesmotic ligament Squeeze test Stress radiographs
Syndesmotic screw
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Metatarsal Examination
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Plantar and Achilles Examination
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Tarsal Examination
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Pott’s Compression Test
Tests for fracture of the tibia or fibula or syndesmotic sprain.
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Syndesmotic Sprain Test
The crossing of the affected leg over the other leg will produce pain with a high ankle sprain of the interosseous membrane.
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Homan’s Test Deep Vein Thrombophlebitis
Supine with knee flexed Abrupt forcible dorsiflexion of foot Positive test produces pain in calf or popliteal region
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Tarsal Tunnel Syndrome
Analogous to carpal tunnel syndrome in the wrist…
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Tinel’s Sign Tap tibial nerve at medial aspect of ankle
Sign is present if paresthesias are produced in foot
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Tourniquet Test Apply sphygmomanometer to affected ankle and inflate to pressure 10 mm of Hg above systolic for 1-2 minutes
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Morton’s Neuroma Pain Usually affect the third and fourth digits
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Metatarsal Pain Patient will often indicate pain over heads of metatarsals
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Metatarsalgia Patient may complain of pain on the dorsum of the foot.
Palpate both dorsal and plantar aspects of foot.
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Metatarsal Inspection
Inspect for callous formations
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Palpate Metatarsal Heads
Attempt to elicit pain and/or tenderness
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Provocative Maneuvers
Metatarsal squeeze Rapid and firm flexion of toes Stretch of interdigital nerves
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Shoulder Ranges of Motion
What are the six ranges of motion for the shoulder?
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History Taking Process
Instability Stiffness Locking Catching Swelling The patient should be asked about shoulder pain:
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Supraspinatus Tendonosis Signs
Painful arc with abduction (60-90) degrees Limited AROM Painful PROM
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Supraspinatus Press Test
Thumb down (empty can) Thumb up (full can)
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Supraspinatus Stress Test
Differentiate deltoid muscle strain from supraspinatus tendon/muscle strain
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Apley Scratch Test
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Apley Scratch Test Rationale
Stresses rotator cuff tendons Supraspinatus is most often involved Exacerbation of pain might indicate degenerative tendonitis
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Hawkins-Kennedy Impingement Supraspinatus tendonitis rationale
Local pain with pressing of supraspinatus tendon against coracoacromial ligament
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Neer Impingement Test Shoulder pain and look of apprehension indicates a positive sign for overuse of supraspinatus tendon Most common cause is repetitive microtrauma
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Bicipital Tendonosis Orthopedic Evaluation
Flexion of the elbow against resistance aggravates pain.
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Bicipital Tendonosis Passive abduction of the arm in a painful arc elicits pain; however, this finding may be negative in isolated biceps tendonitis.
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Speed’s Test Bicipital tendonosis
Patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated.
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Yergason’s Test Biceps tendon instability
The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance with the elbow flexed and the shoulder in adduction. Popping of subluxation of the tendon may be demonstrated with this maneuver.
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Clunk Test Tear of the anterior labrum
Document joint stability in order to assess the rotator cuff and glenoid labrum.
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Rowe Test For multidirectional instability
Attempt to dislocate Look at patient’s face for apprehension and/or discomfort This is a positive sign GH ligament, Rotator cuff tendons and joint capsule
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Abduction Inferior Stability (ABIS) Test Feagin test + anterior inferior shoulder instability with downward displacement or apprehension Patient's arm abducted with the forearm resting on the examiner's shoulder Examiner exerts pressure on the arm, gradually pushing the humeral head downwards
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Crank Test (3) (Standing or seated) or Fulcrum Test (Supine)
This test serves to place the shoulder in a position of maximal instability (extremes of abduction and external rotation). The test is positive for instability if the patient expresses pain or apprehension.
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Relocation Test (4) Classic fulcrum test
The humeral head is pushed forward to elicit apprehension
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Relocation Test Prevents anterior subluxation and produces a negative apprehension test
Pressure over the front of the humeral head prevents the head suluxating anteriorly, and does not cause apprehension.
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Sulcus Test (1) A positive test is indicative of abnormal mobility
In the relaxed patient, the examiner gently pulls the humerus downwards. The test is positive if the humeral head descends, with formation of a groove or sulcus under the lateral border of the acromion
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Drawer Test (2) Demonstrates overall non-specific hyperlaxity or anterior instability of the glenohumeral joint The patient is made to relax and slightly lean forward. The examiner holds the humeral head between his or her thumb and index finger, and tries to make the head slide backwards and forwards.
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Positive Hyperabduction Test Inferior Glenohumeral ligament determines range of passive abduction (85-90 degrees) Marked asymmetry between the affected and the healthy side is characteristic of laxity of the ligament complex. Positive test = 105 degrees plus
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Multidirectional Hyperlaxity
On examination, there will be a groove of more than 2 cm in the sulcus test, as well as major anterior and posterior drawer movements. External rotation of the upper limb of more than 90° is also considered to be a sign of abnormal laxity.
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Isosceles Triangle Use this process to reveal any deviations may indicate anatomical problem that warrants further investigation
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Tinel’s Sign
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Lateral Epicondylitis/Epicondylosis/tendinopathy Tennis Elbow Test or Cozen’s test
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Kaplan’s Test Presence of a Kaplan’s sign with reduced pain and increased strength
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Medial Epicondylitis/Epicondylosis/Tendinopathy Examination
Golfer’s elbow test is a reverse “Cozen’s” test
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Valgus Testing Challenge the flexor muscles
Strain the medial ulnar collateral ligaments
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Ligamentous Instability Adduction and Abduction Stress Tests
Gapping and pain indicate a positive test for instability
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Froment’s Sign Test for ulnar nerve palsy
Tests the action of adductor pollicis Patient holds a piece of paper between the thumb and a flat palm as the paper is pulled away.
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Froment’s Sign and Finger Pinch Test
Patient with an ulnar nerve palsy will flex the thumb to try to maintain a hold on the paper. There are variations of this test
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Pinch Grip Test Anterior interosseous nerve trauma
Observe pitch attitude of the hand Normally when individual pinches something between index finger & thumb, MP & IP joints of thumb and index finger are flexed;
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Pinch Grip Test Anterior interosseous nerve trauma
With nerve deficit, terminal phalanges of thumb and index finger are extended or hyperextended EMG needle examination is difficult because of the deep location
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Elbow Flexion Test Ulnar nerve compression at cubital tunnel
The elbow is the most common site of compression of the ulnar nerve. Second most common compressive neuropathy (after carpal tunnel syndrome). Cubital tunnel syndrome affects men 3-8 times as often as women.
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Examination of Related Areas
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Normal Metacarpal Joints and Contour
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Finkelstein’s Test
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Tunnel of Guyon Ulnar Nerve and Artery
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Phalen’s Test Carpal Tunnel Syndrome
Often, the symptoms can be duplicated or worsened by bending the wrist firmly palmward for 60 seconds
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Tinel’s Sign Carpal Tunnel Syndrome
Tapping the front of the wrist over the nerve reproduces the pain and paresthesia
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Dupuytren’s Contracture
A longitudinal fibrous band, known as a cord, may form. Cord may flex the finger joints Process tends to be progressive
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Ulnar Drift Rheumatoid Arthritis
Drift of the fingers away from the direction of the thumb at the MP joint (ulnar drift). Due to tissue damage of capsules, ligaments, and tendons
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“Boutonniere” Deformity Avulsion of Extensor Digitorum Communis Tendon
Boutonniere deformity is an extensor tendon injury affecting two joints of the finger, the PIP (proximal interphalangeal) joint at the middle of the finger, and the DIP (distal interphalangeal) joint that controls the fingertip.
213
Mallet Finger Avulsion of Distal Extensor Digitorum Communis
The tendon that straightens the tip of the finger is injured and you may lose the ability to straighten your finger
214
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