Inspection
- Generally inspect patients in standing and sitting positions. Examine patients from an anterior, posterior and lateral angle
- Note
- Gait
- Posture and alignment
- Lateral: alignment of ear, shoulder, hip, knee and malleolus
- Posterior: alignment of spinous processes and paravertebral muscles
- Muscle atrophy, hypertrophy, spasm, fasiculation or increased tone (eg. torticollis) and trigger point locations
- Note integumentary findings (lesions, sinus tracts, tufts of hair, signs of trauma, etc.)
- Measure leg length with the true leg length test
- Cervical Spine
- Note cervical curvature
- Postural deformities (head forward/loss of cervical lordosis)
- Landmarks: C7/T1 most prominent spinous process
- Thoracic Spine
- Note thoracic curvature
- Postural deformities (increased kyphosis, scoliosis)
- Shoulder height and symmetry
- Scapulae (resting position, winging, anterior shoulder posture/abducted scapula)
- Height (spinal level) where hands hang
- Lumbosacral Spine
- Note lumbar curvature
- Postural deformities (increased lumbar lordosis, flattening)
- Landmarks: Posterior superior iliac crest (L4 vertebrae), PSIS/sacral dimples (S2 vertebrae)
- Gluteal fold height and symmetry
- Iliac crest height and symmetry
- Approximate leg length discrepancy
Palpation
- Generally note any areas of pain, swelling, spasm, atrophy, deformity or crepitus when palpating:
- Cervical Spine
- Each spinous process C2-C7
- Note any step-offs
- Tenderness: fracture, infection, arthritis, metastatic disease
- Facet joints deep in the trapezius muscle C2-C7
- Paravertebral muscles
- Trapezius muscle
- Sternocleidomastoid
- Thoracic Spine
- Each thoracic spinous process T1-T12
- Note any step-offs
- Tenderness: fracture, infection, arthritis, metastatic disease
- Facet joints deep in paraspinal muscles T1-T12
- Paravertebral muscles
- Scapulae
- Place hand on each scapula when approaching the patient posteriorly. Have patient flex thoracic spine to 45 degrees, if height of hands becomes asymmetrical it is suggestive of scoliosis
- Lumbosacral Spine
- Each lumbar spinous process L1-L5
- Note any step-offs
- Tenderness: fracture, infection, arthritis, metastatic disease
- Paravertebral muscles
- Iliac crests
- Sacroiliac (SI) joints at posterior superior iliac spine (PSIS)/sacral dimples
- Sciatic nerve
- Patient semiprone with hips flexed, palpate midway between ischial tuberosity and greater trochanter, positive if pain elicited
- Specific sciatic tests
Percussion
- Percuss each vertebrae with the hypothenar aspect of a closed fist to detect possible malignancy, degenerative disease or osteomyelitis
- Malignancy
- Post-test probability if positive: 86%
- Specificity for malignancy: 60%
- Osteomyelitis
- Post-test probability if positive: 10.0% (LR+ = 2.1)
- Post-test probability if negative: 1.2% (LR- =0.2)
Range of Motion
- Cervical Spine
- Forward flexion (normal= 45°), "chin to chest"
- Assesses for MS, cervical nerve impingement and B12 deficiency
- Extension (normal= 50°), "look up at ceiling"
- Lateral bending (normal= 45°), "ear to shoulder"
- Assesses for impingement of cervical root and radicular pain
- Rotation (normal= 70°), "turn head from side to side"
- Thoracic Spine
- Note: stabilize hips
- Forward flexion (20°-40°), "lean upper body forward"
- Extension (normal= 30°), "lean upper body backwards"
- Lateral bending (normal= 35°), "lean upper body side to side"
- Rotation (normal= 30°), "rotate upper body from side to side"
- Lumbosacral Spine
- Foward flexion (variable), "touch toes"
- Assesses for ankylosing spondylitis
- Extension (normal= 30°), "bend backwards"
- Have patients place hands on their hips for stability
- Lateral bending (normal= 35°), "bend side to side"
- Rotation (normal= 30°), "turn, looking over each shoulder"
References
- Baxter, S. & McSheffrey, G. (2010). Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
- Bickley L. (2013). Bates Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
- Filate, W., Leung, R., Ng, D. & Sinyor, M. (2005). Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto; 2005.
- Hurley, K. (2005). OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
- Pawa, J., Lesniak, D. & Lott, A. (2011). Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.