The Scanning Examination

Jake Shockley PT, OCS, COMTPhysical Therapy Central

2013

Purpose of the Scanning Exam• To ensure patient presentations are within the scope of physical therapy

practice– Ruling out “serious” pathology

• Neurological compromise – Upper and lower motor neuron lesions

• Severe ligamentous instability• Acute fracture• Any acute or sub-acute lesions with significant inflammatory response

• Briefly consider the presence of regional interdependence (Rob Wainner) or victims and culprits (Erl Pettman) within the quadrant– Cervical or thoracic spine playing a role in the development of rotator cuff tendonitis

Purpose of the Scan• To detect gross loss of function, ROM, and movement control. • The scanning examination should be negative most of the time which

means you will need further testing to determine your PT diagnosis. • The scan alone can help identify common orthopedic lesions that

present acute and or sub-acute. Below are a few…– Lumbar disc herniation– Spinal stenosis– Rotator cuff tendonitis– Cervical radiculopathy

Components of the Scan• Observation• Vital signs• Functional movement testing• Selective Tissue Tension testing• Specific palpation• Neurological exam• Dural and neural tissue tension tests• General stress tests• Special tests

Observation• Look for the obvious…

– Gait deviation• Break down cardinal planes

– Sagittal – flexion vs. extension» Loss of or significant

vertical rise– Frontal – abduction vs.

adduction» Trendelenberg sign

– Transverse – external vs. internal rotation» Excessive lumbopelvic

rotation

– Stance and swing; tolerance, quality, quantity, and position of lower extremity

– Postural deviation– Difficulty with

transitional movement– Scars, structural

deformities, skin creases

Vital Signs

• Blood pressure• Heart rate• Respiratory rate• Pulse– Central and peripheral

Functional Movement Testing

• Upper quadrant– Apley’s test– Grip strength

• Lower quadrant– Functional squat– Single leg stance– Walk on heels (L4), toes (S1)

Selective Tissue Tension Testing• AROM -> Passive overpressure -> resistance.– Cardinal planes

• Flexion• Extension• Side bending• Rotation

– Quadrants• Flexion• Extension

Specific Palpation• Specific palpation of the painful area distinguishing

structures– Muscle belly – trigger point(s)– Musculotendonous junction– Tendonoperiosteal junction– Bony landmarks– Joint line– Nerve trunks

Neurological Exam• Myotome Testing

– Upper Quadrant• C3 – Cervical lateral flexion• C4 – Shoulder elevation• C5 – Shoulder abduction and ER• C6 – Elbow flexion, forearm

supination, wrist extension• C7 – Elbow extension,

wrist/finger flexion• C8 – Thumb extension, wrist

ulnar deviation• T1 – Finger abduction or

adduction

• Myotome Testing– Lower Quadrant

• L1-2 – hip flexion• L3 – knee extension, hip adduction• L4 – ankle dorsiflexion• L5 – Great toe extension, ankle

eversion, hip abduction. • S1 – hip extension• S1-2 knee flexion

• Fatigable weakness– Neurological weakness will fatigue

quickly with repeated myotomal testing

Neurological Exam• Dermatome Testing

– Upper Quadrant• C2 – Suboccipital• C3 – Submandibular angle• C4 – Upper Trapezius• C5 – Lateral deltoid• C6 – Tip of thumb• C7 – Tip of middle finger• C8 – Fifth finger• T1 – Ulnar side forearm• T2 – Axilla

• Dermatome Testing– Lower Quadrant

• L1 – Groin• L2 – Anterior medial thigh• L3 – supra patella• L4 – Dorsum of medial leg and foot• L5 – Dorsum of middle 3 toes,

medial arch• S1 – Lateral foot, 5th toe, posterior

leg• S2 – Posterior thigh• S3 – posterior medial thigh

Neurological Exam• DTRs

– UQ • C4 - Levator scapula• C5 – Deltoid• C6 – biceps, brachiorad• C7 – Triceps• C8 – Ext Pollicis Longus• T1 – Hypothenar

– LQ• L3 – hip adductors, patella tendon• L4 – Anterior tibialis• L5 – Fibularis longus, EDM• S1 – Achilles tendon

• Upper motor neuron tests– Hoffman’s – flick middle finger,

watching for index and thumb flexion reflex.

– Babinski – scraping movement with end of reflex hammer plantar surface calcaneus to forefoot.

– Clonus – quick passive movement with hold. A positive is more than 3 beats• Wrist extension • Ankle plantar flexion.

Neural and Dural tissue testing.• Upper Quadrant

– Median– Ulnar– Radial – Slump

• Lower Quadrant– SLR– Prone knee bend– Slump

General Stress Tests

• Spine – Central P/As– Unilateral P/As

• Extremities– Valgus/varus, anterior, posterior, rotatory –

Quadrant testing

Special Tests

• Upper Quadrant– Cervical – Spurling’s, traction, figure eight– Shoulder – Empty can, O’Brians, Neers

impingement– Elbow – quadrant test, Active floor push-up sign,

Cozen’s test, Tinnel’s sign, Flexion compression test (ulnar nerve)

Special Tests• Lower Quadrant– Lumbopelvic – SI gapping/compression, lumbar traction,

prone lumbar torsion, prone instability test, SLR, treadmill test

– Hip – Standing rotation, FABERS, FADIR, Stitchfield’s (ASLR)– Knee – Thessaly’s, joint line tenderness test, Appley’s

compression test, patellar step test, Homan’s sign– Foot/ankle – talar swing, navicular drop

APPENDIX

Upper Quarter Screen

http://youtu.be/i8lJ5Tz9fvw

Lower Quarter Screen

http://youtu.be/5Co5SEteXNI

Cyriax Terminology

• Strong and painful – think minor muscle lesion • Strong and pain free – muscle is clear• Weak and painful – think major muscle lesion• Weak and pain free – neurological lesion or

full thickness tear

Maitland Mobilization Grades• Grade I - Small amplitude rhythmic oscillating mobilization in early range of

movement• Grade II - Large amplitude rhythmic oscillating mobilization in midrange of

movement• Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation

in range of movement• Grade IV - Small amplitude rhythmic oscillating mobilization at end range of

movement• Grade V (Thrust Manipulation) - Small amplitude, quick thrust at end range of

movementReference: http://www.physio-pedia.com/Manual_Therapy

SINSS

• Severity – intensity of patients complaint• Irritability – the amount of activity to

aggravate/alleviate symptoms• Nature – the source of the patient’s pain• Stage – acute, sub-acute, chronic• Stability – better, same or worsening

Resources• Treatment Based Classification – Password: OUHSC • Clinical Prediction Rule – Password: OUHSC• Physical Therapy Central – Resource Page for regional

interdependence articles and more.• Subacromial Impingement Syndrome