Illustrated Orthopedic Physical Assessment

1200 Pages·2008·101.71 MB·English

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ABOUT THE AUTHOR
Dr. Ronald C. Evans is a Doctor of Chiropractic and a 1976 System of the ACA and a Forum Acquisitions Editor for the
graduate of Northwestern Health Sciences Univeristy, and ACA Press.
Chaired its Chiropractic Orthopedics Residency Program Dr. Evans was an appointee by Iowa Governor Terry E.
from 1980 to 1984. He is a Diplomate of the American Branstad to the Iowa Health Reform Council, the Iowa
Board of Chiropractic Orthopedists (DABCO) and Exam Health Regulation Review Task Force, and the Iowa Comm
iner Emeritus of that Board. He is a Fellow of the Academy unity Health Management Information System (CHMIS).
of Chiropractic Orthopedists (FACO) and Examiner Emeri He is the CEO of the Iowa Chiropractic Physicians Clinic,
tus of that Board. Dr. Evans is a Fellow of the International (ICPC) a single-specialty independent provider network for
College of Chiropractors (FICC), and has lectured in ortho Iowa and surrounding Midwestern states.
pedics and neurology for 35 years, speaking extensively Dr. Evans is the recipient of the Chiropractic Orthopedist
throughout the United States, Canada, New Zealand and of the Year Award (1984) and the Distinguished Service
Australia, and Scotland. Dr. Evans has lectured on the cam Award (1994) from the American College of Chiropractic
puses of Northwestern Health Sciences, Drake University, Orthopedists, receiving the ACCO Distinguished Service
Texas College of Chiropractic, Logan University/College of Award again for 2001-2002. The Council on Chiropractic
Chiropractic, Southern California University of Health Sci Orthopedics recognized Dr. Evans for Lifetime Achieve
ences, and Palmer College of Chiropractic, Western States ment in 1992 and he received the President's Citation for
Chiropractic College, as well as at the Center for Alternative Distinguished Service by the American Board of Chiroprac
Medicine Research, Harvard Medical School. Dr. Evans has tic Orthopedists in 1991. Dr. Evans received the Award of
addressed diverse audiences that include the Association of Excellence in 1993-1994, the Presidential Award in 1994,
Trial Lawyers of Iowa, the American Bar Association, the and the Outstanding ICS Member in 1996-1997, all from the
Australian Chiropractor's Association, the Defense Research Iowa Chiropractic Society. Most recently, he received the
Institute of the American Bar Association, the American Iowa Board of Chiropractic Examiners Service Award:
Public Health Association, and the Royal Academy of Iowa Chiropractic Society 1990-2001. Dr. Evans received
Physicians and Surgeons. the Distinguished Service Award from the Academy of
Dr. Evans is retired from an 11-year term of office on the Chiropractic Orthopedists in March 2003.
Iowa Board of Chiropractic Examiners, serving as chairper Dr. Evans' writings include Orthopedic Test and Signs, A
son of the Board for nearly half that term. He maintains a Compendium, NWUHS, 1979, third edition, 1984, 1985;
private practice in Des Moines, and is the senior chiroprac Differential Diagnosis of Conditions Presenting Neck and
tic orthopedic staff of a multi-provider, multi-disciplinary ArmPain,NWCC, 1980, second edition, 1984,1985; Ortho
health care facility specializing in the non-surgical manage pedic Considerations of the Low Back and Lower Extremity,
ment of orthopedic and neurological disorders. He is a NWUHS, 1980, second edition, 1984, 1985; The Impair
Trustee of the Foundation for Chiropractic Education and ment Rating, NWCC, 1981, second edition, 1984; "The
Research, and served as Editorial Advisor for its publication Injured Worker: Role of the Chiropractor," Journal of the
"Staying Well" for many years. Dr. Evans is the Vice Presi Australian Chiropractor's Association; 1985; 15(2); "Malin
dent of FCER and continues to serve the FCER as the Chair gering and Symptom Embellishment," Chapter 15, Chiro
man of its Department of Defense Committee. Dr. Evans is practic Family Practice, Williams & Wilkins, 1990; Thoracic
the Chair of the Evidence-Based Resource Center of FCER. Spinal Examination Procedures; audio lecture for DC
He was an appointee to the RAND Consensus Panel for the TRACTS bimonthly publications, 1989, 1990; "Truncal
study of the Appropriateness of Manipulative Care for the Pain," Chapter 5, as a contribution to Scoliosis, by D. Asper-
Cervical Spine. He is an appointee, by the Secretary of gren, Williams & Wilkins, 1991; "Back School; a statistical
Defense of the United States, to the Oversight Advisory correlation to demonstrate efficacy of a Back School Educa
Committee for Chiropractic Health Care, Department of tion Program in the therapeutic regimen: a one year study,"
Defense, now serving as a Senior Member of that Commit completed 12/31/82; "CPT/ICD-9 coding and reference
tee, as well as its successor committee, the Chiropractic glossary" for Iowa Chiropractic Society; The Role of The
Healthcare Benefits Advisory Committee. Dr. Evans has Doctor of Chiropractic In Health Care Reform in The State
served as an Editorial Advisor for DC TRACTS, and is a of Iowa Within the Context of the Principles of Reform Of
Prepublication Book Reviewer for Lippincott Williams & the Iowa Health Reform Council; Notice of Intended Action
Wilkins Publishers; Elsevier, and Aspen Publishing. He is Insurance Division [191], New Chapter 75, "Iowa Individ
an Associate Editor for the Journal of Neuromusculoskeletal ual Health Benefits Plans"; Managed Care In The United
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ABOUT THE AUTHOR (CONTINUED)
States Perspectives on Chiropractic Health Care Delivery Memorex," Iowa Trial Lawyers Association Medical
in Total Managed Care Systems, 1995; Noticed Rules, Damages Seminar June 9, 1995; Testing Methodology
Chapter 110, "Center for Rural Health and Primary Care," and Protocol of the American Board of Chiropractic
New Section. 514c. 11 Patient Access to Types of Physicians Orthopedists, Evans RC, Brandt JR; Evans RC, Rosner
Under Managed Care Health Plan or Indemnity Plan With AL. "Alternatives in Cancer Pain Treatment: The Applica
Limited Provider Network; Analysis of the Final Report on tion of Chiropractic Care," Seminars in Oncology Nursing
the Physician Utilization Study as authorized by Iowa State 2005;21(3):184-189. His textbooks include The Illustrated
Senate, Senate File 2470(1996) and completed by Donald Essentials in Orthopedic Physical Assessment, 1993; Illus
G. Hamm, Jr., FS A William M. Mercer, Incorporated, as the trated Orthopedic Physical Assessment, 2001; and Instant
Clinical and Cost Effectiveness of Various Types of Physi Access to Orthopedic Physical Assessment, 2002; and Iatro
cians for the Iowa Division of Insurance January 6, 1997 by genic Tendinopathy Associated with Levaquin (Levofloxa-
Ronald C. Evans, DC, FACO, FICC, and Anthony I. Rosner, cin); case report, 2008.
Ph.D. February 10, 1997; Fibromyalgia: A Conservative Dr. Evans holds the copyright and trademark for the
Perspective on Definition, Diagnosis and Management, a Greenfield Babinski Neurological Reflex Hammer;
video presentation for FCER 5/95; Identifying and Under IMPSTAT (a computer program for the Evaluation and
standing Lateral Elbow Pain with Emphasis on Lateral Epi Rating of Physical Impairments (coauthored with Logic
condylitis; Alternative Medicine: Implications for Clinical Unlimited, Inc.); and he is the co-developer of EXAM-
Practice Chiropractic Health Care; Basic Chiropractic MAKER, a computerized exam-making program, based on
Testing and Evaluation Techniques PAIN: "Is it real, or is it multi-statistical permutations, with Logic Unlimited, Inc.
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PREFACE
The basic observation of a patient's painful stance and Readers will enjoy the "At the View Box," contributions of
aggravating movements usually allows the formulation of Dr. Timothy Mick, DC, DACBR, as well as the expanded
the presenting signs and symptoms into a recognizable con critical thinking elements. Illustrated Orthopedic Physical
stellation of a disease syndrome. The essence of orthopedic Assessment, Third Edition, remains clinically relevant and
diagnosis is the clinically demonstrable or reproducible useful for both the student and the practicing clinician.
signs of disease or injury. The scope and organization of Illustrated Orthopedic
Many physicians associate an aura of mysticism with the Physical Assessment, Third Edition, makes it a suitable com
ease and speed with which the orthopedic specialist arrives panion for the clinician at all levels of sophistication, pro
at a diagnosis. In fact, the specialist's development of inter gressing from the initial procedures of orthopedic diagnosis
viewing, observation, and physical testing skills allows pro to the requirements of the advanced student and the experi
ceeding directly to the heart of the patient's problem. enced practitioner. Included in the thirteen chapters are diag
I have been privileged in clinical practice to be chal nostic facts in orthopedics, organized in a manner most
lenged by the myriad orthopedic health problems presented likely to be useful during the examination of patients. The
by my patients. I believe that my early and fumbling years book's compact physical dimensions invite constant use as
were well tolerated by these gracious people. They became a reference volume on the physician's office desk, in the
well in spite of my efforts. They have remained loyal instrument bag, and in the clinical setting; its functional
indeed. internal design, with liberal use of Orthopedic Gamuts,
In these latter years of practice, many of the early patients offers a convenient vehicle for refreshing one's memory
return with new diseases. These maladies are often much about seldom encountered and easily forgotten clinical
more difficult to diagnose and treat. My skills as an ortho orthopedic phenomena.
pedic specialist have been honed to a fine edge out of neces Only the unusual reader and clinician could master
sity. Some of these patients will not outlive me to give me the contents of Illustrated Orthopedic Physical Assessment
yet another chance to get it right. by studying it in sequence from beginning to end. Rather,
The perspective of the role of the physician in modern the student or clinician should digest the principles and
medicine has changed. Physicians are no longer viewed as procedures in segments as general diagnostic knowledge
the omnipotent beings they were formerly thought to be. The progresses. First, the reader should become familiar with
physician is expected to recognize personal skill limitations Chapters 1 and 2 and the descriptions of the "Cardinal
and make appropriate consultations and referrals. Patients Signs and Symptoms". From these chapters, the clinician
expect the correct diagnosis the first time around. At the should explore the regional chapters. As contact with
least, they deserve that. patients increases and specific questions arise, the reader
This book is created to alleviate the frustration and dis should become familiar with the "Comments" for each
comfort for two parties in their respective quests for health diagnostic procedure. The "Comments" section of each
and wellness. First are the physicians and orthopedic spe test or sign amplifies the knowledge of an underlying
cialists, who labor mightily in pushing, pulling, poking, pathology that is often discovered with the pertinent test or
bending, and twisting patients' body parts in the sometimes procedure.
less than compassionate search for the cause of the suffering. Chapter 13 presents rationale and procedures for inves
Second are the patients who have been not-so-gently pushed, tigating malingering or non-organically-based complaints.
pulled, poked, bent, and twisted into inhuman configurations Included with Chapter 13 are numerous medical record
as they wait furtively for the discovery of the cause of their forms, outcomes assessment forms, and pain scale analogs.
anguish. I salute both parties for their endurance in seeking Each chapter of Illustrated Orthopedic Physical Assess
the origin of disease and discomfort. ment, Third Edition, has a specific format. The format lends
Although the first edition of Instant Access to Orthopedic to the quick referencing of tests and maneuvers and cross-
Physical Assessment was an unqualified success—voted into referencing of associated procedures.
the 1994-1995 Top 250 Books of the Year by Doody's Each chapter begins with indexing of the tests found
Health Sciences Book Review Journal—it could be made to therein. Each chapter also begins with cross-reference
be better. Much of what made the first edition so successful tables for the syndrome assessed and by the syndrome sus
succeeded into a second edition, and now a third edition. pected. Further, each chapter presents the separate protocols
There are many major changes to the contents: increasing for the regional joint assessment procedures and for assess
the information on disease assessment, including more illus ment of pain in the particular joint or region. These are
trations, and creating many more Orthopedic Gamuts. presented as testing procedural flow charts. These charts
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PREFACE (CONTINUED)
identify the test procedure(s) used to objectify the symptoms than one test or sign. In a problem-oriented situation,
of pain, paralysis, weakness, and loss of sensation. The chart eponyms are routinely used in the physical evaluation
provides a plan of examination and selections of tests for process. Familiarity with the terms and techniques used
the joint. in determining regional problems enables the physician
Each chapter begins with a set of axioms. Axioms are and assistant to record and clarify an orthopedic examina
self-evident or universally recognized truths. Axioms are tion. Following the name of the test, maneuver, or sign is
also established rules, principles, or laws. An axiom used in identification of the specific pathology the test is suited to
this text is also a principle accepted as true, without proof elicit.
as the basis for argument. A test is part of the physical examination in which direct
Each chapter introduction addresses the various unique contact with the patient is made. It also may be a chemical
considerations or pathologies of the focal joint. The intro test, x-ray, or other study. All tests described in his book will
ductory section contains the index of the tests presented and relate to the physical examination.
illustrated in the chapter. A sign is elicited by a test or a particular maneuver. A
Laced throughout a chapter are Orthopedic Gamuts. sign can be simply a visual observation (e.g., antalgia), and
The various gamuts present a range or spectrum of facts or it is an indication of the existence of a problem perceived
concepts in assessing orthopedic disease. The gamuts in by the examiner.
each chapter may represent universal orthopedic precepts as A maneuver is a complex motion or series of move
well as specific regional principles and maxims. The gamuts ments, used either as a test or treatment. A maneuver is also
serve as diagnostic rubric in examining a patient. a method or technique.
Essentia] anatomy is presented in each chapter. The A phenomenon is any sign or objective symptom or any
essential anatomy section is not all-encompassing, but rather observable occurrence or fact.
discusses only the typical tissues that can be examined in A law is a description of a phenomenon that is so thor
orthopedic physical procedures. oughly tested and accepted that it is regarded as a principle
Essential motion assessment for the joint is included. governing like phenomena.
These illustrations depict the expected full ranges of move For each testing procedure in the book, a general
ment for the joint. The discussion further identifies the comment is presented about the pathologic condition tar
amount of lost motion that can affect the activities of daily geted by the test. Numerous citations from current research
living. literature annotate the discussions of underlying patholo
Essential muscle function for each joint is also included. gies. Following the comment section is a bulleted delinea
This section identifies the musculature that is the prime tion of how the test is conducted. Each procedure is supported
mover of the joint, the innervation, and the action of the by photo illustrations and legends.
muscle, and limited discussion of the muscular anatomy. Each test is cross-referenced with other supportive tests
Essential imaging elements are addressed in each and procedures as "Next Steps/Procedures". Where perti
chapter, specific for the region or joint discussed. Again, not nent, a "Clinical Pearl" identifies the subtle nuances or
all imaging techniques or modalities are discussed, only finesse of the tests that the author has gleaned from empiri
those procedures germane to the physical orthopedic testing cal practice.
of a patient. For selected tests or procedures, At the Viewbox case
Each test, maneuver, sign, law, or phenomenon is pre studies are presented. The case studies exemplify the typical
sented separately. The common usage name for the test, as and salient diagnostic image findings for the disease pathol
identified in Stedman's, Taber's, Mosby's, Dorland's, or ogy discussed. The case studies have been graciously sup
Churchill's medical dictionaries, is the heading for the test. plied from the teaching library of Dr. Timothy Mick, DC,
Equally, common synonyms and eponyms follow this DACBR.
name. At the close of each chapter, a "critical thinking" section
Eponyms for certain examinations vary from locale to is included. The critical thinking section is a range of ques
locale or among institutions within the same area. Such tions germane to the specific region or joint of the chapter.
observations are a reflection of the training center's influ The questions pertain largely to information contained in
ence. This is especially true where the names of prominent this text, but may occasionally require the reader to cross-
local physicians or clinicians or researchers are frequently reference with other pieces of literature or current scientific
used for these examinations. On occasion, the same test is journals. The answers for each question are contained in this
given two or more names, or the name can apply to more reference as well.
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PREFACE (CONTINUED)
The references are listed for each chapter. The biblio authors. Their works are exemplary in great scientific
graphic listing is new, updated, and extensive. In some writing, strongly contributing to the fund of knowledge of
instances, the bibliography reflects older volumes or works modern physicians. The artwork and line drawings used in
than are commonly found in scientific literature today. These these works are unsurpassed.
older references are the original work of the creators of Although the various tests and procedures in this book
various tests or procedures in this book. Preserving are presented in an anatomical or regional format, the appli
the books in these reference lists is an attempt to pre cation of the tests is accomplished in a more natural flow of
serve a continuum in the development of orthopedic examination procedures. The natural flow of the examina
investigation. tion usually moves the patient from the standing position,
In an effort to accurately depict tissues and pathology through sitting, supine, and side-lying positions to the prone
involved in orthopedic disease and injury, numerous new position. Appendix A is a Listing of Tests, Alphabetically
illustrations are included in Illustrated Orthopedic Physical and Anatomically; Appendix B is a Listing of Tests Accord
Assessment, Third Edition. Largely the new illustrations are ing to the Position of the Patient. A Glossary of Abbrevia
from the outstanding and benchmark works of selected tions is also included.
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