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ILLUSTRATED ORTHOPEDIC PHY SICAL ASSE SSMENT. Third Edition ISBN: 978-0-323-04532-2
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The Publisher

ISBN: 978-0-323-04532-2

Vice Presidel1l and Publisher: Linda Duncan

Senior Acquisitions Editor: Kcllie F. White
Senior Developmental Editor: Jennifer Watrous
Associate Developmental Editor: Kelly Milford
Publishing Services Manager: Julie Eddy
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Designers: Renee Duenow, Jessica Williams

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 DEDICATION

For Linda,

Inspiration Everlasting

For

PiS, VR, iG, KB, MAB, CG, LA, CR, KR, DR, RM , RS, iC, PS, MLP, DRG NIR , ,

is, MF, RH, MRN, SAA, EIW, MAN, LLS, FLvw, RMS MRA, SMR, ID, CMC, MC, ADS ...
,

and all other patients, past and present, participating in my continued search for their wellness ...

For iRB

... because many scientific premises first illuminate in eddies of single malts, plumes of Cuban smoke, and at the
end of tight lines ...a consummate physician/scientist ...

And finally,

For my mother:

An Irish woman who bore a Welsh son. I am blessed by her endless creativity and, compassion, and gift of gab.
Were it not for her, I would have less to say ... how very dull.
 ABOUT THE A U T H O R
Dr. Ronald C. Evans is a Doctor of Chiropractic and a 1976
graduate of Northwestern Health Sciences Univeristy, and
Chaired its Chiropractic Orthopedics Residency Program
from 1980 to 1984. He is a Diplomate of the American
Board of Chiropractic Orthopedists (DABCO) and Exam-
iner Emeritus of that Board. He is a Fellow of the Academy
of Chiropractic Orthopedists (FACO) and Examiner Emeri-
tus of that Board. Dr. Evans is a Fellow of the International
College of Chiropractors (FICC), and has lectured in ortho-
pedics and neurology for 35 years, speaking extensively
throughout the United States, Canada, New Zealand and
Australia, and Scotland. Dr. Evans has lectured on the cam-
puses of Northwestern Health Sciences, Drake University,
Texas College of Chiropractic, Logan University/College of
Chiropractic, Southern California University of Health Sci-
ences, and Palmer College of Chiropractic, Western States
Chiropractic College, as well as at the Center for Alternative
Medicine Research, Harvard Medical School. Dr. Evans has
addressed diverse audiences that include the Association of
Trial Lawyers of Iowa, the American Bar Association, the
Australian Chiropractor's Association, the Defense Research
Institute of the American Bar Association, the American
Public Health Association, and the Royal Academy of
Physicians and Surgeons.
Dr. Evans is retired from an 11-year term of office on the
Iowa Board of Chiropractic Examiners, serving as chairper-
son of the Board for nearly half that term. He maintains a
private practice in Des Moines, and is the senior chiroprac-
tic orthopedic staff of a multi-provider, multi-disciplinary
health care facility specializing in the non-surgical manage-
ment of orthopedic and neurological disorders. He is a
Trustee of the Foundation for Chiropractic Education and
Research, and served as Editorial Advisor for its publication
"Staying Well" for many years. Dr. Evans is the Vice Presi-
dent of FCER and continues to serve the FCER as the Chair-
man of its Department of Defense Committee. Dr. Evans is
the Chair of the Evidence-Based Resource Center of FCER.
He was an appointee to the RAND Consensus Panel for the
study of the Appropriateness of Manipulative Care for the
Cervical Spine. He is an appointee, by the Secretary of
Defense of the United States, to the Oversight Advisory
Committee for Chiropractic Health Care, Department of
Defense, now serving as a Senior Member of that Commit-
tee, as well as its successor committee, the Chiropractic
Healthcare Benefits Advisory Committee. Dr. Evans has
served as an Editorial Advisor for DC TRACTS, and is a
Prepublication Book Reviewer for Lippincott Williams &
Wilkins Publishers; Elsevier, and Aspen Publishing. He is
an Associate Editor for the Journal of Neuromusculoskeletal
System of the ACA and a Forum Acquisitions Editor for the
ACA Press.
Dr. Evans was an appointee by Iowa Governor Terry E.
Branstad to the Iowa Health Reform Council, the Iowa
Health Regulation Review Task Force, and the Iowa Comm-
unity Health Management Information System (CHMIS).
He is the CEO of the Iowa Chiropractic Physicians Clinic,
(ICPC) a single-specialty independent provider network for
Iowa and surrounding Midwestern states.
Dr. Evans is the recipient of the Chiropractic Orthopedist
of the Year Award (1984) and the Distinguished Service
Award (1994) from the American College of Chiropractic
Orthopedists, receiving the ACCO Distinguished Service
Award again for 2001-2002. The Council on Chiropractic
Orthopedics recognized Dr. Evans for Lifetime Achieve-
ment in 1992 and he received the President's Citation for
Distinguished Service by the American Board of Chiroprac-
tic Orthopedists in 1991. Dr. Evans received the Award of
Excellence in 1993-1994, the Presidential Award in 1994,
and the Outstanding ICS Member in 1996-1997, all from the
Iowa Chiropractic Society. Most recently, he received the
Iowa Board of Chiropractic Examiners Service Award:
Iowa Chiropractic Society 1990-2001. Dr. Evans received
the Distinguished Service Award from the Academy of
Chiropractic Orthopedists in March 2003.
Dr. Evans' writings include Orthopedic Test and Signs, A
Compendium, NWUHS, 1979, third edition, 1984, 1985;
Differential Diagnosis of Conditions Presenting Neck and
ArmPain,NWCC, 1980, second edition, 1984,1985; Ortho-
pedic Considerations of the Low Back and Lower Extremity,
NWUHS, 1980, second edition, 1984, 1985; The Impair-
ment Rating, NWCC, 1981, second edition, 1984; "The
Injured Worker: Role of the Chiropractor," Journal of the
Australian Chiropractor's Association; 1985; 15(2); "Malin-
gering and Symptom Embellishment," Chapter 15, Chiro-
practic Family Practice, Williams & Wilkins, 1990; Thoracic
Spinal Examination Procedures; audio lecture for DC
TRACTS bimonthly publications, 1989, 1990; "Truncal
Pain," Chapter 5, as a contribution to Scoliosis, by D. Asper-
gren, Williams & Wilkins, 1991; "Back School; a statistical
correlation to demonstrate efficacy of a Back School Educa-
tion Program in the therapeutic regimen: a one year study,"
completed 12/31/82; "CPT/ICD-9 coding and reference
glossary" for Iowa Chiropractic Society; The Role of The
Doctor of Chiropractic In Health Care Reform in The State
of Iowa Within the Context of the Principles of Reform Of
the Iowa Health Reform Council; Notice of Intended Action
Insurance Division [191], New Chapter 75, "Iowa Individ-
ual Health Benefits Plans"; Managed Care In The United
vii
 ABOUT THE A U T H O R ( C O N T I N U E D )
States Perspectives on Chiropractic Health Care Delivery
in Total Managed Care Systems, 1995; Noticed Rules,
Chapter 110, "Center for Rural Health and Primary Care,"
New Section. 514c. 11 Patient Access to Types of Physicians
Under Managed Care Health Plan or Indemnity Plan With
Limited Provider Network; Analysis of the Final Report on
the Physician Utilization Study as authorized by Iowa State
Senate, Senate File 2470(1996) and completed by Donald
G. Hamm, Jr., FS A William M. Mercer, Incorporated, as the
Clinical and Cost Effectiveness of Various Types of Physi-
cians for the Iowa Division of Insurance January 6, 1997 by
Ronald C. Evans, DC, FACO, FICC, and Anthony I. Rosner,
Ph.D. February 10, 1997; Fibromyalgia: A Conservative
Perspective on Definition, Diagnosis and Management, a
video presentation for FCER 5/95; Identifying and Under-
standing Lateral Elbow Pain with Emphasis on Lateral Epi-
condylitis; Alternative Medicine: Implications for Clinical
Practice Chiropractic Health Care; Basic Chiropractic
Testing and Evaluation Techniques PAIN: "Is it real, or is it
Memorex," Iowa Trial Lawyers Association Medical
Damages Seminar June 9, 1995; Testing Methodology
and Protocol of the American Board of Chiropractic
Orthopedists, Evans RC, Brandt JR; Evans RC, Rosner
A L . "Alternatives in Cancer Pain Treatment: The Applica-
tion of Chiropractic Care," Seminars in Oncology Nursing
2005;21(3):184-189. His textbooks include The Illustrated
Essentials in Orthopedic Physical Assessment, 1993; Illus-
trated Orthopedic Physical Assessment, 2001; and Instant
Access to Orthopedic Physical Assessment, 2002; and Iatro-
genic Tendinopathy Associated with Levaquin (Levofloxa-
cin); case report, 2008.
Dr. Evans holds the copyright and trademark for the
Greenfield Babinski Neurological Reflex Hammer;
IMPSTAT (a computer program for the Evaluation and
Rating of Physical Impairments (coauthored with Logic
Unlimited, Inc.); and he is the co-developer of E X A M -
M A K E R , a computerized exam-making program, based on
multi-statistical permutations, with Logic Unlimited, Inc.
 PREFACE
The basic observation of a patient's painful stance and
aggravating movements usually allows the formulation of
the presenting signs and symptoms into a recognizable con-
stellation of a disease syndrome. The essence of orthopedic
diagnosis is the clinically demonstrable or reproducible
signs of disease or injury.
Many physicians associate an aura of mysticism with the
ease and speed with which the orthopedic specialist arrives
at a diagnosis. In fact, the specialist's development of inter-
viewing, observation, and physical testing skills allows pro-
ceeding directly to the heart of the patient's problem.
I have been privileged in clinical practice to be chal-
lenged by the myriad orthopedic health problems presented
by my patients. I believe that my early and fumbling years
were well tolerated by these gracious people. They became
well in spite of my efforts. They have remained loyal
indeed.
In these latter years of practice, many of the early patients
return with new diseases. These maladies are often much
more difficult to diagnose and treat. My skills as an ortho-
pedic specialist have been honed to a fine edge out of neces-
sity. Some of these patients will not outlive me to give me
yet another chance to get it right.
The perspective of the role of the physician in modern
medicine has changed. Physicians are no longer viewed as
the omnipotent beings they were formerly thought to be. The
physician is expected to recognize personal skill limitations
and make appropriate consultations and referrals. Patients
expect the correct diagnosis the first time around. At the
least, they deserve that.
This book is created to alleviate the frustration and dis-
comfort for two parties in their respective quests for health
and wellness. First are the physicians and orthopedic spe-
cialists, who labor mightily in pushing, pulling, poking,
bending, and twisting patients' body parts in the sometimes
less than compassionate search for the cause of the suffering.
Second are the patients who have been not-so-gently pushed,
pulled, poked, bent, and twisted into inhuman configurations
as they wait furtively for the discovery of the cause of their
anguish. I salute both parties for their endurance in seeking
the origin of disease and discomfort.
Although the first edition of Instant Access to Orthopedic
Physical Assessment was an unqualified success—voted into
the 1994-1995 Top 250 Books of the Year by Doody's
Health Sciences Book Review Journal—it could be made to
be better. Much of what made the first edition so successful
succeeded into a second edition, and now a third edition.
There are many major changes to the contents: increasing
the information on disease assessment, including more illus-
trations, and creating many more Orthopedic Gamuts.
Readers will enjoy the "At the View Box," contributions of
Dr. Timothy Mick, DC, DACBR, as well as the expanded
critical thinking elements. Illustrated Orthopedic Physical
Assessment, Third Edition, remains clinically relevant and
useful for both the student and the practicing clinician.
The scope and organization of Illustrated Orthopedic
Physical Assessment, Third Edition, makes it a suitable com-
panion for the clinician at all levels of sophistication, pro-
gressing from the initial procedures of orthopedic diagnosis
to the requirements of the advanced student and the experi-
enced practitioner. Included in the thirteen chapters are diag-
nostic facts in orthopedics, organized in a manner most
likely to be useful during the examination of patients. The
book's compact physical dimensions invite constant use as
a reference volume on the physician's office desk, in the
instrument bag, and in the clinical setting; its functional
internal design, with liberal use of Orthopedic Gamuts,
offers a convenient vehicle for refreshing one's memory
about seldom encountered and easily forgotten clinical
orthopedic phenomena.
Only the unusual reader and clinician could master
the contents of Illustrated Orthopedic Physical Assessment
by studying it in sequence from beginning to end. Rather,
the student or clinician should digest the principles and
procedures in segments as general diagnostic knowledge
progresses. First, the reader should become familiar with
Chapters 1 and 2 and the descriptions of the "Cardinal
Signs and Symptoms". From these chapters, the clinician
should explore the regional chapters. As contact with
patients increases and specific questions arise, the reader
should become familiar with the "Comments" for each
diagnostic procedure. The "Comments" section of each
test or sign amplifies the knowledge of an underlying
pathology that is often discovered with the pertinent test or
procedure.
Chapter 13 presents rationale and procedures for inves-
tigating malingering or non-organically-based complaints.
Included with Chapter 13 are numerous medical record
forms, outcomes assessment forms, and pain scale analogs.
Each chapter of Illustrated Orthopedic Physical Assess-
ment, Third Edition, has a specific format. The format lends
to the quick referencing of tests and maneuvers and cross-
referencing of associated procedures.
Each chapter begins with indexing of the tests found
therein. Each chapter also begins with cross-reference
tables for the syndrome assessed and by the syndrome sus-
pected. Further, each chapter presents the separate protocols
for the regional joint assessment procedures and for assess-
ment of pain in the particular joint or region. These are
presented as testing procedural flow charts. These charts
ix
 PREFACE ( C O N T I N U E D )
identify the test procedure(s) used to objectify the symptoms
of pain, paralysis, weakness, and loss of sensation. The chart
provides a plan of examination and selections of tests for
the joint.
Each chapter begins with a set of axioms. Axioms are
self-evident or universally recognized truths. Axioms are
also established rules, principles, or laws. An axiom used in
this text is also a principle accepted as true, without proof
as the basis for argument.
Each chapter introduction addresses the various unique
considerations or pathologies of the focal joint. The intro-
ductory section contains the index of the tests presented and
illustrated in the chapter.
Laced throughout a chapter are Orthopedic Gamuts.
The various gamuts present a range or spectrum of facts or
concepts in assessing orthopedic disease. The gamuts in
each chapter may represent universal orthopedic precepts as
well as specific regional principles and maxims. The gamuts
serve as diagnostic rubric in examining a patient.
Essentia] anatomy is presented in each chapter. The
essential anatomy section is not all-encompassing, but rather
discusses only the typical tissues that can be examined in
orthopedic physical procedures.
Essential motion assessment for the joint is included.
These illustrations depict the expected full ranges of move-
ment for the joint. The discussion further identifies the
amount of lost motion that can affect the activities of daily
living.
Essential muscle function for each joint is also included.
This section identifies the musculature that is the prime
mover of the joint, the innervation, and the action of the
muscle, and limited discussion of the muscular anatomy.
Essential imaging elements are addressed in each
chapter, specific for the region or joint discussed. Again, not
all imaging techniques or modalities are discussed, only
those procedures germane to the physical orthopedic testing
of a patient.
Each test, maneuver, sign, law, or phenomenon is pre-
sented separately. The common usage name for the test, as
identified in Stedman's, Taber's, Mosby's, Dorland's, or
Churchill's medical dictionaries, is the heading for the test.
Equally, common synonyms and eponyms follow this
name.
Eponyms for certain examinations vary from locale to
locale or among institutions within the same area. Such
observations are a reflection of the training center's influ-
ence. This is especially true where the names of prominent
local physicians or clinicians or researchers are frequently
used for these examinations. On occasion, the same test is
given two or more names, or the name can apply to more
x
than one test or sign. In a problem-oriented situation,
eponyms are routinely used in the physical evaluation
process. Familiarity with the terms and techniques used
in determining regional problems enables the physician
and assistant to record and clarify an orthopedic examina-
tion. Following the name of the test, maneuver, or sign is
identification of the specific pathology the test is suited to
elicit.
A test is part of the physical examination in which direct
contact with the patient is made. It also may be a chemical
test, x-ray, or other study. All tests described in his book will
relate to the physical examination.
A sign is elicited by a test or a particular maneuver. A
sign can be simply a visual observation (e.g., antalgia), and
it is an indication of the existence of a problem perceived
by the examiner.
A maneuver is a complex motion or series of move-
ments, used either as a test or treatment. A maneuver is also
a method or technique.
A phenomenon is any sign or objective symptom or any
observable occurrence or fact.
A law is a description of a phenomenon that is so thor-
oughly tested and accepted that it is regarded as a principle
governing like phenomena.
For each testing procedure in the book, a general
comment is presented about the pathologic condition tar-
geted by the test. Numerous citations from current research
literature annotate the discussions of underlying patholo-
gies. Following the comment section is a bulleted delinea-
tion of how the test is conducted. Each procedure is supported
by photo illustrations and legends.
Each test is cross-referenced with other supportive tests
and procedures as "Next Steps/Procedures". Where perti-
nent, a "Clinical Pearl" identifies the subtle nuances or
finesse of the tests that the author has gleaned from empiri-
cal practice.
For selected tests or procedures, At the Viewbox case
studies are presented. The case studies exemplify the typical
and salient diagnostic image findings for the disease pathol-
ogy discussed. The case studies have been graciously sup-
plied from the teaching library of Dr. Timothy Mick, DC,
DACBR.
At the close of each chapter, a "critical thinking" section
is included. The critical thinking section is a range of ques-
tions germane to the specific region or joint of the chapter.
The questions pertain largely to information contained in
this text, but may occasionally require the reader to cross-
reference with other pieces of literature or current scientific
journals. The answers for each question are contained in this
reference as well.
 PREFACE ( C O N T I N U E D )
The references are listed for each chapter. The biblio-
graphic listing is new, updated, and extensive. In some
instances, the bibliography reflects older volumes or works
than are commonly found in scientific literature today. These
older references are the original work of the creators of
various tests or procedures in this book. Preserving
the books in these reference lists is an attempt to pre-
serve a continuum in the development of orthopedic
investigation.
In an effort to accurately depict tissues and pathology
involved in orthopedic disease and injury, numerous new
illustrations are included in Illustrated Orthopedic Physical
Assessment, Third Edition. Largely the new illustrations are
from the outstanding and benchmark works of selected
authors. Their works are exemplary in great scientific
writing, strongly contributing to the fund of knowledge of
modern physicians. The artwork and line drawings used in
these works are unsurpassed.
Although the various tests and procedures in this book
are presented in an anatomical or regional format, the appli-
cation of the tests is accomplished in a more natural flow of
examination procedures. The natural flow of the examina-
tion usually moves the patient from the standing position,
through sitting, supine, and side-lying positions to the prone
position. Appendix A is a Listing of Tests, Alphabetically
and Anatomically; Appendix B is a Listing of Tests Accord-
ing to the Position of the Patient. A Glossary of Abbrevia-
tions is also included.
-
xi
 ACKNOWLEDGMENTS
Many individuals come to mind for their contributions to
the continuum of this reference work, and they are indeed
too numerous to list. They are, especially, the physicians
who attend my lectures and symposia and take the time
to tell me about or demonstrate for me various orthopedic
tests and signs. I am sure that in many instances the unin-
formed or casual onlookers thought that grown men were
wrestling in public, when, in fact, we were exchanging the
latest testing procedures. I will always be grateful to these
keepers of the empirical body of medicine and science.
Without their thirst for knowledge and scientific evidence
and support, this book could not be written or continue in
its evolution.
More specifically, I must acknowledge three great mentors
in chiropractic orthopedics: Dr. Joseph J. Sweere, Dr.
Russell G. Hass (dec), and Dr. Robert N. Solheim (dec).
It was my fortune to be their student in orthopedic health
science. Their challenges kept me advancing in my funda-
mental knowledge in orthopedic medicine, and their educa-
tional excellence caused me to grow. This book is a product
of that growth. Their guidance and vitality have been the
breath of life for the entity of orthopedic specialization
within the scope of chiropractic practice. Perhaps more
especially, I acknowledge Dr. John F. Allenberg, former
President, Northwestern University of Health Sciences, as
the individual responsible for my completion of the arduous,
if not overwhelming, residency program at Northwestern.
Although I may have had the talent and intellect for the task,
he provided the necessary stimulus at the right times to help
me see the endeavor to completion. Without that, I would
not be a chiropractic orthopedist.
It is hard to define the driving force that propels one to
aspire to excellence. Samuel C. Evans, DC, my father, and
partner in practice, in his life and love of quietly but effi-
ciently caring for people, embodied the greatest attributes in
health science and art. His dedication to truth in science and
compassion in ministering to the sick and injured inspired
me to greater heights as a physician and as a person. This
book, the editions before it, and those that will come after,
is penned with eternal respect, admiration, and humility for
his lifetime work and contribution to the human condition.
The greatest man I ever knew.
My contemporary, Dr. James R. Brandt, continued to
serve in the development of the third edition of this text, as
well as for its companion, Instant Access to Orthopedic
Physical Assessment, Second Edition. Dr. Brandt remained
steadfast in critical assessment of the work and dedicated to
making me strive for excellence in my writing.
Dr. Kim A. Skibsted contributed to the third edition with
astute clinical photography. Dr. Skibsted's keen eye and
sense of photographic composition are unparalleled and
add to the advancement of the images used in various chap-
ters. In many instances, the clinical photography of Dr.
Skibsted is unsurpassed in depicting important positions
and postures. Dr. Skibsted not only grasped the concept
and framing issues of the illustrations, he worked tire-
lessly to perfect the quality of this book. I am ever
indebted.
For the third edition, Mrs. Linda K. Evans saw to it that
manuscripts for both Illustrated Orthopedic Physical Assess-
ment, Third Edition, and Instant Access to Orthopedic Phys-
ical Assessment, Second Edition, were ready, accurate, and
finished ahead of time. Her zeal to make these editions as
successful as the previous ones is unparalleled. She made
the task of revision more interesting and less heavy. I will
seek her guidance for future works.
For the third edition—and to quote, "It takes a village"
—to produce the stunning new color images for the various
tests and maneuvers. At the outset, Logan University/
College of Chiropractic president Dr. George Goodman,
and Dr. Elizabeth Goodman, Ms. Ann Carter, Assistant to
Drs. Goodman, and Ms. Kim Sullivan, Graduation &
Event Planner at the Purser Center, are commended for their
generosity in providing a magnificent location for the author,
crew, editorial photographer, and models, in the production
of the art. The Purser Center is unparalleled in its beauty and
functionality. Certainly, the college administration and staff
saw to every need for this project, ensuring its success. I am
grateful to the ITC company for providing the set backdrop
and carpet, without which, the art would be less charming.
Mr. Jim Visser, primary still photographer, and Mr.
Chuck Leroi, and his videographic assistants Matt
Aiskenen, and Ryan Cannon, could not have worked harder
to achieve any higher degree of excellence with the color
photos and illustrations and video footage. They both pushed
the models to exceed their known abilities, squeezing out
every detail of movement or position. Their collective work
embodies the constant search for perfection, serving as a
guide for me to create prose equal to the illustrations. I look
forward to working with both in future endeavors.
The primary photographic models include Ms. Kim
Alvis, Mr. Sean Brasfleld, Ms. Candyse Burns, Mr. Ryan
Collart, Mr. Ochuko Ekpere, Ms. Angela Fain, Dr. LT
Faison, Ms. Sheena Gordon, Mr. John Knott, Mr. Patrick
Milford, Ms. Julie Mowczuo, Mr. Gary Taylor, and Ms.
Annie Walters. Both Mr. Brasfield and Dr. Faison rose far
above the call of duty in providing either specialized and
critical equipment for the photos, or in helping recruit suit-
able models for the shoot. Each of the models demonstrated
interminable patience in achieving just the right position or
xiii
 ACKNOWLEDGMENTS
look of a test or procedure. I am grateful for their stamina
and physical pliability. It is worthwhile noting that some of
these able models subsequently entered successful practice
as chiropractic physicians.
Ms. Bailey Schechinger is a superb model for the clini-
cal illustrations. She was tireless, well-poised, and eager to
learn the meanings and usefulness of the procedures. Because
of this, she helped make this book better.
The Mosby/Elsevier staff for this edition included: Ms.
Jennifer Watrous, Senior Developmental Editor, Health
Professions 1 department of Editorial. I am pleased that Ms.
Watrous elected to engage in the work on my new editions.
She worked diligently on the second edition of Illustrated
Orthopedic Physical Assessment, and it has been exciting to
have her working on the third. Her attention to detail previ-
ously made the book into a definitive reference. That same
perseverance with editing my writing this time pushes the
book yet one notch higher. It is always a pleasure to work
with people who truly want to see a project succeed. Ms.
Watrous exemplifies this trait. Ms. April Falast, Editorial
Assistant, Health Professions I department of Editorial. We
could not have completed the work on time or in an orga-
nized fashion without Ms. Falast's creative work in making
the photographic masters from the second edition. The
enlarged illustrations were the perfect tool for both the stills
and videos. I am sure this was hard work, but the resulting
photo catalog is unsurpassed. I am also grateful for her atten-
tion to the needs of the models. Without Ms. Falast's leader-
ship, I am certain the freezing models would simply have
left the building, along with Elvis. Ms. Kelly Milford, Asso-
ciate Developmental Editor, Health Professions 1 depart-
ment of Editorial, is exceptional in her work. Her attention
to detail and dedication to completion of the project kept the
manuscripts, models, photographers, and the author moving
forward. I am ever indebted to her patience in waiting for
the final draft(s). Her professionalism is unsurpassed, espe-
cially tested in frequent e-mail and tele-conference contact
from the beginning until the first bound copy. One could not
xiv
(CONTINUED)
ask for more of an editor. Her activities in compiling the
manuscript schedules, arranging the photo shoot, arranging
for the models and organizing the video and audio studios,
as well as keeping everyone on the same page were invalu-
able. I could not have done any of the work without her at
the "director's table." Ms. Andrea Campbell, Senior Project
Manager, juggled communication with numerous staff con-
stantly. She was the last stop before the "work" becomes a
book. She is the sous chef for my manuscripts: I gave her
the ingredients and she turned them into something everyone
will like to look at and want to read. Ms. Campbell helped
to sort out the art problems and keep track of what needed
to be redrawn and what needed replacing (according to my
seemingly interminable corrections). Quite a task. I am ever
grateful for her skills. Ms. Kellie White, Senior Acquisi-
tions Editor, Health Professions I department of Editorial.
Worked with me from the earliest stages of Illustrated
Essentials in Orthopedic Physical Assessment, through to
Illustrated Orthopedic Physical Assessment, Second Edition,
and Instant Access to Orthopedic Physical Assessment, and
now for Illustrated Orthopedic Physical Assessment, Third
Edition, and Instant Access to Orthopedic Physical Assess-
ment, Second Edition. Ms. White continues to provide the
necessary latitude and unwavering encouragement for the
development of both books to evolve them into nationally
recognized, definitive works. She embodies the attributes of
a senior editor for which every author hopes. She and her
excellent staff brought professionalism, interest, and dedica-
tion to the project. I have now written two editions under
her guidance, with great result. The current revisions will
surpass both our expectations, which I attribute to her skills
at marshaling all the creative elements, models, photogra-
phers, and the author, to their best. Developing a book with
her and for her is a joy. Elsevier is both astute and fortunate
to have Ms. White in its Editorial leadership, and I am for-
tunate to enjoy her friendship and creative counsel. I will
continue to strive to give her the best manuscripts. I look
forward to future collaborations.
Solving a patient's health problem can be a demanding exer-
cise of orthopedic medical detection and logical deduction.
Each health problem is a new diagnostic jigsaw puzzle for
which the pieces must be found and fitted together in a care-
fully organized manner.
Each examination or investigation should have a plan for
including or excluding a specific member of a "short list" of
suspected conditions. It is always the failure to have such
an organized plan or approach that makes the diagnosis of
orthopedic health problems so artificially difficult. Certainly,
common or customary steps must be followed, but not blind
routine or blunderbuss investigations.
Diagnosis purely by comparison with previous cases is
reserved for the physician or orthopedic specialist who is
very experienced and very accurately remembers the cases,
but this combination is not the norm. The entry level physi-
cian or orthopedic specialist will come nearer to diagnostic
accuracy by progressing logically through the medical
investigation paradigm.
Despite all this, however, the right approach will never
be achieved until one misconception is laid to rest. This
misconception is that the exact solution of an orthopedic
problem does not matter very much and that such a solution
will be of academic interest only, with no useful nonsurgical
treatment. Such a view is nonsense. It is true that health
science is frustrated in treating motor neuron disease; no
cure exists for hereditary ataxia, and no reliable method
exists to prevent relapses in disseminated sclerosis. Contrary
to many beliefs, these diseases occupy only a small part of
the orthopedist's time.
Think for a moment of the transformation in the last 30
years in the treatment of cervical spine trauma, interverte-
bral disc prolapse, carpal tunnel syndrome, and deficiency
neuropathies. Think of the influence of physiologic thera-
peutics in hypersensitivity states and in acute episodes of
soft-tissue disease, of the continuing progress of manipula-
tive therapy in certain facets of the migraine headache
process, mechanical lower-back disorders, and in trigeminal
neuralgia. Consider the advances of chiropractic orthopedics
in treating various forms of benign spinal compression.
Finally, the solution of an orthopedic problem takes time.
A solution cannot be rushed, and the examiner must never
allow the approach to be influenced by the exhortations of
optimistic colleagues to "just glance at this case while
passing" or to "just run over the musculoskeletal system, it
won't take 5 minutes." It will, it always does, and so it
should.
XV
 1 Principles in Assessing
Musculoskeletal Disorders, 1
2 Assessing Cardinal Musculoskeletal
Symptoms and Signs, 48
3 Cervical Spine, 75
4 Shoulder, 205
5 Elbow, 324
6 Forearm, Wrist, and Hand, 375
7 Thoracic Spine, 467
8 Lumbar Spine, 535
9 Pelvis and Sacroiliac Joint, 699
10 Hip, 765
11 Knee, 843
12 Lower Leg, Ankle, and Foot, 929
13 Malingering, 1004
Glossary of Abbreviations, 1141
Appendix A, 1149
Appendix B, 1151
Answers to Critical Thinking
Questions, 1153

xvii
 AXIOMS IN ASSESSING MUSCULOSKELETAL
DISORDERS
Eliciting the patient's history is the quintessential skill
in orthopedics.
• An examiner needs to learn about the patient's major
pre enting symptoms, the chronology of the disorder.
and its impact on the patient's activities of daily living,
as well as ancillary information that include history
and involvement of other systems.
The orthopedic examination is the focal activity in
assessing the patient's musculoskeletal complaint.
The orthopedic examination process is adapted to the
specific needs of the patient's musculoskeletal system,
such as inspection, palpation, and observation.
INTRODUCTION
Health care providers assess patients every day in clinical
practice. Commonly, clinical practice is impossible wiLhoUl
structured assessments and tests. Examination procedures
appear to be straightforward: results are either positive or
negative. However, all assessment and testing in clinical
practice is based on the assumption of uncertainty: Does the
patient have a disease? The probability of a particular disease
can be established only by performing a test or a chain of
test.s.
The accuracy of a test for detecting a disease or a condi­
tion is determined by sensitivity and specificity. A high
sensitivity (or a high specificity) does not uffice to make a
test lIseful in clinical practice: a test should be as sensitive
as possible. The sensitivity and specificity of examination
procedures and tesLS can often be found in the literature.
Sensitivity and specificity are important characteristics of
evidence-based physical assessment procedures but only in
the context of a specific disease or condition.
The probability of a disease or condition after having
performed a test (Bayes theorem) is dependent on two
things: (I) the specificity and sensitivity of the procedure
(test characteristics) and (2) the probability of the disease or
condition before conducting the procedure. Interpretation of
Bayes' theorem is that the probability of having a disease is
not only dependent on the lest or examination procedure
result and the characteristics of the procedure, but is also
l)I�llllll'II)ll (,\\\l I t I
ORTHOPEDlC EVALUATlON
PROCESS
The orthopedic evaluation process has three phases:
I. History taking
2. Examination
3. Diagnosis
l)I�lIllll'II)I( l,\\\l I I'
CLlNlCAL ASSESSMENTS
In clinical practice, assessments occur all day, every
day, including:
I . Elucidating complaints
2. Establishing impact of the complaints
3. Checking the complaint consistency with specific
diagnoses
4. Performing a general physical examination
5. Performing special physical examinations
6. Performing laboratory and imaging tests
7. Interpreting test results
8. Formulating a diagnosis
9. Commencing lreaunent
10. Evaluating treatment efficacy
I I . Referring to a specialist, as needed
dependent on how likely the existence of the disease is
before the procedure is actually conducted. This likelihood
is dependent on the prevalence of the disease.
The decision on whether to perform a new test depends
on the resu lt of the previous test. Procedures with the lowest
burden. risk. and costs for the patient are performed first,
and those with the highest burden. risk. or costs are reserved
for specific patients in which the prior probability is highest.
Examination procedures in the context of a low prior prob­
ability of disease is rarely, if ever. informative. The yield of
diagnostic testing will increase the prior probability in the
range of approximately 50%. Very experienced clinicians
intuitively apply these rules and arrange rheir diagnostic
process in such a way that the highest possible yield (a
2 CHAPTER I Principles in Assessing Musculoskeletal Disorders
llRIIIIlJ'1 \lIt t;AM1J I I l
BAYES THEOREM
Rules of Thumb rationale for use in clinical
situations:
I. Highly sensilive and specific lest, will not perform
very well in the clinical context if the a priori prob­
ability is very low,
2, No single diagnostic test exists that tums an a priori
risk of disease of less than 10% into a probabil.ity that
makes a clinician sufficiently convinced to establish
a diagnosis,
3, lhting is most valuable if the a priori probability of
the disease is somewhere in the range of 40% to
60%,
4, Diagnostic tests can turn such a probability into a
sufficiently high posttest probability onto which to
base further action.
OIU 1101'1 \lIt t;AMlIl I 4
PRECIS OF PHYSICAl
EXAMINATION
Sensitivity and speciticity do not exclusively make a
•
diagnostic test as appropriate for clinical use,
• Test results that are considered normal or abnormal
should always be interpreted in the context of the
individual patient.
The probability of having a disease is not totally
dependent on the test result and the characteristics of
the test.
The probability of having a disease is also dependent
on how prevalent the disease is before the test is actu­
ally conducted,
Testing in the context of a low probability of disease
is rarely. if ever, informative.
Highly sophisticated and costly diagnostic techniques
•
may fail as easily as simple, cheap, diagnostic
maneuvers.
highly probable diagnosis) will be oblained at the lowest
possible burden, risk, and costs for the patient. Less experi­
enced clinicians may learn from experienced colleagues by
recalling Bayes theorem and implemcming ils principles in
everyday clinical practice.
Health care provider� cannot function adequately without
physical examination procedures. In the real world, examin­
ers accomplish ciinicul practice appropriately witholll a
deJailed knowledge of the principles of tests, However, the
benefits from physical testing can be easily increased by
recognizing that Lhese tests do nothing more than increase
the probability of a certain condition or diagnosis. Test
results are never infallible.
BOX I-I
PRECIS IN ORTHOPEDIC DIAGNOSIS
I. HistOry
2. Examination
3. Determination of disability lPILS):
,F:revcntable causes of disability
Independent living
hifeslyle
SOCial support
From the moment of the first encounter with a pmient,
the examiner is simultaneously observing and examining the
movements and mannerisms of the patient. as well as listen­
ing to what is being said, The diagnostic process is complex;
the examiner needs to establish the physical issues that are
of greatest imponance to the patient (those most disrupting
to the activities of daily living) and try to differentiate the
anatomic and pathologic aspects of any disease or injury that
might be present.
The history provides much information about what dif­
ficulties the patient is experiencing and the impact of these
difficulties on the patient. Orthopedic examination is essen­
tial to define the structures involved; together. these pro­
cesses allow differentiation of orthopedic disorders into
various diagnostic cat.egories (Box I-I).
HISTORY TAKING
A carefully elicited history is a most crucial element in
onhopedic assessment. An experienced examiner can form
an idea of the extent and magnitude simply frol11 the patiem's
history. I n the modern era of electronic patient medical
record keeping, the examiner has new lools and melhods for
not only capturing patient infomlation. but also tracking
clinically significant changes.
Health care providers arc increa�ingly under pressure to
deliver efficient and high-quality care. Irnponant reasons for
this pressure arc the ageing population. increasing demands
and expectations by patients, rbing medical cOst.l.. and a
decrea.l.c of full-time cmployed spccialists. Various innova­
tions in information technology have been proposed to
enhance the efficiency and quality of health cart.!. Conse­
quences of these innovations are altered health care pro­
cesses. as well as a redefinition or responsibilities and a
change in workload for caregivers and patients involved in
these processes. A health care innovation that is increasingly
applied in 1l1:;IIlY medical specialties is telcmedicine (TM).
TM can be defined as "the use of telecommunications tech­
nology for medica,1 diagnostic. monitoring and therapeutic
purpoSC!\ when distance andlor time scparmcs the partici­
pants" (Bcrgholll ct al. 2006).
A recent Institute of Medicine (10M) report charactcr­
i/cd increased utilization of advances in health care informa-
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
(lRI I I(l I'II) III,A�\lI11 ,
An integrated electronic patient record (EPR) is essen­
tial for the future of health care services.
The EPR assists in the sharing of patient infomlation
and helps promote efficiency.
The most important resource for the development of
the EPR is the patient.
Computer systems can take appropriate directed
medical histories from patients based on chief com­
plaint.
lion technology (IT) (e.g.. automation of clinical, financial.
and administrallve transactions) as essential 10 improving
quality and efficiency. preventing errors. and enhancing
comumcr confidence in the health care sy�lem. Research
shows that IT loo h •. such as computerized clinical decision
suppon <iy,lcm .. and computerized physician order entry.
can Improve phy...ician perrormance and puticm outcomes
(Nowill..,ki et al . 2007).
Clearly. IT ha!\ had an cxtraordinilry impact on the provi­
,ioll of health service.... Over 40 years ha� passed since the
vision of a comprehensive electronic patient record (EPR)
system wa<.; first e<.;tahlished. Integration of the EPR has been
less than successful partly because it relics heavily on
physician<.; and other highly skilled professionab for daw
acquisition. Some EPR systems ha....e 3l1emplCd to improve
physician usc and acceptance by st3ndardiLing medical
prose or creating templates; acceptance is Mill suboptimal
(Benamia. Elinson. Zarnke. 2(07).
Bun and Hmg found that although 73Ck of physician
offices u..,ecl computer.., for billing. only 17% lIsed them for
mainw1l1ing medical records and 8ift. for ordering prescrip­
tion.... The proponion of U.S. physicians who have adoptcd
electronic health rccords is estimated to be between 20% and
25tH (Schleyer. Spallck. Hernandez, 2(07).
The complaint history of a musculoskeletal condition
covers certain essential points. History of trauma helps dif­
ferentiate between acquired ligamentous (soft-tissue) insuf­
ficiency, inherent laxity, and past instability. Ii" trauma or
overuse caused t.he problem, the examiner must determinc
whether the patient stopped the injurious activity immedi­
ately and self-treated the resulting condition. Finding
lraumali/ed joints and adjacent Mructures neglected. decon­
ditioned. weakened. or atrophied caused by prolonged
periods of protection is common.
An accurate description of the traumatic event. including
the exact position of the part at the moment of injury, is
essential.
The exact site of the pain is also important. Patients
often identify pain in one location. such as the hip, but
point somewhere else, such as the sacroiliac joint. The more
distal the pain is, the morc accurately patients detine its
location.
3
I
OIU Illll'lllll I;A�Il'1 1 (,
WORKlNG DIAGNOSIS
Essential steps in formulating a working diagnosis
include:
I. History taking
2. Observation
3. Palpation
4. Orthopedic testing
5. Clinical laboratory and imaging procedures
llR1 IIlll' Illlt l,\"l'l 17
OBSERVATION AND INSPECTION
Observation and inspection of the patient occur
anytime during the examination or history
interview, especially when the patient is not aware
of the observation. In this way, the examiner notes:
I. Antalgia or deformities of poslure
2. Gait disturbances, especially if the patient needs
assistance
3. Spinal synunelry, including prominences or eleva­
tions, flattening or depressions, scoliosis, or abnor­
malities of the anteroposterior curValure
4. Surface scars and wounds
CHIEF COMPLAINT
Patients who have more than one complaint, such as those
with pain of spinal origin coupled with other body region
symptoms or extremity problems. must be guided in ranking
the complaints in priority. Although patients occasionally
seek attention for stiffness or some other joint-related com­
plaint, most patients with musculoskcletal conditions do so
for reasons related to pain, especially when it compromises
the activities of daily living.
The basic elements of examining the patient include
observation and inspection. palpmion. neurologic evalua­
tion. vilal signs, range-of-motion studies, clinical laboratory
'lUdies. orthopedic tests, and diagnostic imaging.
Mo ...t examiner� perfonn routine cOll1prehcn�ivc cxal11l1la­
tiom, on patients with even minimal initial chief compl:lint�
(Phelps. Rodriguez. 2005).
OBSERVATION AND INSPECTION
The first impressions-observations made while taking the
patient's history-are often the most revealing.
Reasoning within the�c (pain-based dinical) categories
appears LO be useful in helping providers and patients under-
4 CHAPTER I Principles in Assessing Musculoskeletal Disorders

stand and account for c1inicaJ presenwuons of pain. Such
reasoning influences planning of phy.!.ical assessments and
lreatment (Smart. Doody, 2007).
A useful approach in the clinical examination of the neu­
romusculoskeletal system is to seek answers to the Critical
ORl lllll'llll( (,A�HlI I X
PAIN-BASED CLINICAL
REASONiNG
Five main categories of pain-based clinical
reasoning are:
• Biomedical (structural-functional source)
Psychosocial (perception-interpretation of pain)
Pain mechanisms (underlying pathophysiologic
factors)
• Chronicity (temporal aspects of pain)
Irritability or severity (degree of pain)
(lRllltll'l niL (,AMlil I ')
5 questions for an orUmpedic specialist. Once all five ques­
tions are answered, a differential diagnosis can usually be
established (Box 1-2).
A rapid general screening examination suffices initially.
Abnormal joints are subjected to a more focused regional
orthopedic examination procedure.
The examiner must detennine the presence of active or
current inHammation. the presence of irreversible joint
damage from past. injury or inflammation, and existing
mechanical defects. These findings are not mutually exclu­
sive.
The distribution of joint involvement is important in
reaching a diagnosis. Certain patterns characterize specific
disorders. The number of involved joints may also be of
diagnostic significance.
Learning what exacerbate!> or relieves the symptom
pattern is important. Equally important is how long the com­
plaints have existed (Table I-I) .
Several other features may be of diagnostic importance.
Some of these features produce skin signs or nodules. Exam­
ples include rheumatoid nodules (Fig. I-I), gouty tophi
(Fig. 1-2), dermatomyositis (Fig. 1-3), and psoriatic arU"itis
(Fig. 1-4).

DETERMINING EXTENT OF
INJURY BOX 1-2

Other characteristic features of diagnostic CR.ITlCAL QJlESTIONS IN OR.THOPEDIC

importance in determining the extent of the disease PHYSICAL EXAMINATION
or injury:
I. Are any joints abnormal'?
1. Is involvement symmetric or asymmetric?
2. What is the nature of the abnormality?
2. Are large or small joints affected? 3. What is the extent of the involvement'?
3. Is the distribution of the condition peripheral or axial? 4. Are Olher features of diagnostic importance present?
4. Does the condition affect upper versus lower limbs, 5. Do the answers to questions I tJlrough 4 provide sufficient
or vice versa? data?

fAKlrl·t

JOINT PATTERNS IN ORTHOPEDiC/RHEUMATIC DISORDERS

Peripheral! Upper!
Number or JOints Large/SmaU Central Lower
Diagnosis Symmetry lnvolved* .Joints Distribution Limb Predilection

Rheumatoid arthritis Symmetric M ono-, oli g o-. polyarth rit is Large/sm all Pe ripheral Uppe rllow er MCPs. PIP,.
MTPs. DIPs
Ankylosing spondylitis Cenlral Sacroiliac
joints. hip,
sh ou lder
Psoriatic arthritis Asymmetric PO lyart hri tis Large/sma ll Peri pheral Uppcrllower DIPs, sacro i li ac
join ts
Reactive arthritis A!iymmctric 01 igoarthri lis/Polyanhri lis Large P eriph eral Lower Sacroiliac
join L'I. DIPs
(toes)
Gou t As ym me tri c MonoarthritislOligoarthritis Large/s ma ll P eri ph era l Lower m ore First MTP,
than upper Knee. Hip

DIPs. Distal interphalangeal joints: Mep.\'. mctacarpoph,lIangeal joints: MTP\. mClalarsophalangcills; PIPs. proxirmll interphalangeal joints.
*Monourthritis dellotes inflammation in a single joint. oligoarthritis Jenoles two to four joint1.. lind polyu
� 1hrilis
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
FIG. I-1 A, Rheumatoid nodules. B, Large nodules may
develop in the olecranon bursa as well as in the subcutane­
ous (issue. (From Klippel JH. Dieppc PA: Rhelllll(l(% gy. 1'0//-2. ed 2.
London. 1998, Mosby.,
F I G. 1-2 Gouty tophi represent deposits of urate crystals.
(From Klippel JH. Dicppc PA: Nlli'1I/1I0to/OKI'. '0'011-2. cd 2. London. 1998.
Mo�by.)
The answers to the Critical 5 questions usually provide
sufficient information to establish a differential diagnosis.
They mu�l. Ir not, the examiner will need 10 retrace each
examination step ullIil a logical and credible diagnosis can
be reached.
5
FIG. 1-3 Skin and nail fold lesions seen in dermatomyosi­
lis. Patches (A) and periungual edema and nail fold (B).
(From Klippel JH. Dicppc PA: Rhe"l/IlllOlog.\; vol 1-2. cd 2, London. 1998.
Mo!.by.)
F IG. 1-4 Psorialic anhritis, with swelling of the distal inter­
phalangeal joint and pitting in the adjacent fingernails. (From
Klippel HI, Dicppc PA: R"elll/llifOlog.\� vol 1·2. cd 2. London. 1998.
Mosby.)
PALPATION
Palpation is the process of assessing the physical character­
istics of joints and contiguous structures by touching or
feeling the palienes body. The purpose of palpation is to
locate and substantiate areas of tenderness, swelling, and
abnormal muscle LOne. Palpmion allows the examiner to
identify a localized increase or decrease in surface tempera­
ture and the presence of induration and mass. Palpation is
classically performed with the fingerlips or Wilh the blum
end of a cotton·lip applicator. However, instruments can be
used in percussion (gently tapping with a renex hammer).
Wilh vibralion (using a C-128 lUning fork).
6 CHAPTER I Principles in Assessing Musculoskeletal Disorders

() I� I I I () 1'1 I ) I ( (, \ \\ I I I III

SPINAL PALPATION
Effective spinal palpation can be accomplished with
the patient in the silling or kneeling variants of
Adam's position:
• In palpating various structures, the examiner assesses
the skin and subcutaneous tissue. Rolling of the skin
(Kibler's test) can be perfonned. The examiner
observes for surface temperature, hypesthesia, hyper­
hidrosis, and muscle splinting.
• Tenderness of muscles and tendons and their attach­
ments is assessed, in both the anatomic resting posi­
tion and through various ranges of motion. FIG. 1-5 From top to bottom, the Greenfield Babinski reflex
hammer, Taylor reflex hammer, Buck's neurologic hammer,
and Babinski reflex hammer.

Tendon sheaths and bursae are palpated for thickness,

crepitus (especially silken versus snowball crepitus), and
tenderness. The joints are palpated for all anatomic compo­
nents to include bones, capsule, ligaments, any specialized
structures, swelling. a change of shape or defornlity, posi­
tional deficits, and tenderness. Palpation also aids in estab­
lishing the integrity of local circulation.
Using a stethoscope or similar instrument improves crep­
itation grading by enhancing the auditory component in con­
junction with palpation and is especially useful with patients
who display mild or moderate crepitation grade subclassifi­
cations.

NEUROLOGIC EVALUATION

The neurologic evaluation involves locating the lesion;

testing deep tendon, superficial, and pathologic reftexes
(Fig. 1-5); testing cranial nerve and brainstem function;
measuring body parts (mensuration); grading muscular
strength; and testing the gross sensory
(Fig. 1-6).
Cerebral dysfunction is determined during the consulta­
lion by nOling the patient's mannerisms and orientation to
time, space, and body pans (usually noted in the chan as
oriented x3). Funher evaluations of lesions in the cerebrum
require advanced imaging procedures and electroneurodiag­
nos tie testing.
Cerebellar lesions are characterized
cogwheel-type muscle actions while the patient's eyes arc
open. The posterior columns of the spinal cord are the source
of the dy function when repeated muscle actions are smooth
and occur while the patient's eyes arc open. However, these
same muscular actions cannot be repeated as smoothly with
the eyes closed. Brainstem dysfunction is discerned through
testing of the cranial nerves. The type and quality of paraly­
sis, reflexes, muscle lone, clonus. atrophy, fasciculation, and
reaclions of degeneration can differentiate spinal cord lesions
from lower motor neuron disorders.
Moritz Heinrich Romberg (1795-1873), the founder of
clinical neurology in Germany. described his now famous
modalities
FiG. 1-6 Single-tipped cotton applicators are both eco­
nomical and versatile and can be used in the following set­
tings: in emergency rooms, examining rooms, outpatient
clinics, and laboratories and on dressing cans. Sterile tongue
depressors are usually made from white Birchwood that is
'/..-inch thick. These tongue depressors are evenly cut and
highly polished for smooth and clean edges, ends, and sur­
by repeated
faces.
sign in the second edition of his Lehrbuch der Nen1en·
kmnkheiten des Metlsc/len (1851). After discussing a reduc­
tion of the motor power in the lower extremities. Romberg
stales, ··The individual keeps his eyes on his feet to prevent
his movements from becoming still morc unsteady. If he is
ordered to close his eyes while in the erect posture. he at
once commences to tolter. The insecurity of his gait also
exhibits itself more in the dark·' (Romberg. 1853). Romberg
thought lhe sign was pathognomonic of tabes dorsalis (Cole.
Michael. Roben, 2(03).
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 7

I
(}1�111(} 1 'lll l ( (,\\11 I I I I (liZ I II(1 1' I Il l( (, \ \\ I I I I 1

DEEP-TENDON REFLEXES CRANIAL NERVES AND BASIC

FUNCTION
I . Scapulohumeml C5-C6
2. Biceps C5-C6 I: Smell
3. Radial C5-C6 II: Vision
4. Triceps C7-C8 IJI : Light accommodation
5. Wrist C7-C8 I I I, IV, V I : Eye movement
6. Ulnar C8-T I v: Sensation (wink)
7. Patellar L2-L4 VII: Facial muscle (taste)
8. Hamstring L4-S I VIII: Auditory (balance)
9. Achilles 51-52 IX: Taste (gag)
x: Voice (swallow)
XI: Shoulder (shrug)
XII: Tongue (motor)
tlIZIII(lI'l l l l ( (,\\111 1 1'

SU PERFICIAL REFLEXES
J . Corneal IJ I, V lll� I I Illl'l 111( (,\ \I I I I I,
2. Upper abdominal 17-T9
COMMONLY ACCEPTED
3. Lower abdominal T I (}..T 12
DEEP-TENDON REFLEX
4. Cremasteric
GRADING SCHEME
5. Gluteal
6. Plantar 0 = Absent
7. T l 2-L2 I = Diminished or hyporeactive
8. L4-LS 2 = Average
9. S I -S2 2+ = Slightly exaggerated (hyperreactive)
3 = Exaggerated (hyperreactive)
4 = Associated with myoclonus

tl l Zllltl l'lllIl (,\\11 I I 1\

PATHOLOGIC REFLEXES comraction in the opposite upper or lower extremities

(Jendrassik maneuver).
J. Hoffmann
lendrassik faci litation is different between age groups
2. Babinski
and weight bearing versus non-weight bearing. Young
3. Chaddock
patients often demonstrate a significant lendrassik facilita·
4. Oppenheim
tion effect in the standing position, whereas. very often, no
5. Bechterew-Mendel
difference is seen in the elderly patients.
6. Rossohmo
Mensuration of body parts is used to determine atrophy
7. Gordon
and functional and anatomic abnormalities (Fig. J.7).
8. Schaeffer
Grip strength testing examines the functjon of the ulnar
nerve and can help differentiate myoneural dysfunction
from malingering activity ( Fig. \·8). The examiner can use
Deep·tendon renexes help the examiner locate the lower three methods of grip strength evaluation (one trial, the
motor neuron lesion and differentiate it from an upper motor mean of three trials. and the best of three trials) when using
neuron lesion. the Jamar dynamometer. Two different sLHtic grip tests are
Superficial renexes differentiate lower motor neuron the five-rung test and the maximal static grip test.
lesions from upper motor neuron lesions. Thc five-rung tc�t involve� perrorming one repetition (trial)
Pathologic renexes determine the presence of upper with the handle or the Jamar dynamometer on each of the
molor neuron lesions. rive handle sCllings. whereas the ma"imal static grip tc�t
Cranial nerve function is dClcmlined by testing brainslcm involves performing three repetitions with the handle on
activity. either lhe second or third sCILing (Fess. 1992: Joughin el 31.
On occasion, eliciting a particular renex is difficult; dis· 1993).
lrJclion techniques are helpful in such situations. If Jcss­ The main difference between the static grip test and the
than-nannal reactivity is encountered in the upper or lower rapid exchange grip ( REG) maneuver is the duration of the
extremities, the patient is directed to perfonn an isometric muscular contraction during gripping.
8 CHAPTER I Principles in Assessing Musculoskeletal Disorders

FIG. I-750ft linen tape is marked in inches on one side

and centimeters on Ihe other. The fast-read ing clinical ther­
FIG. 1-8 Manin Vigorimetcr aneroid dynamomeler (left)
mometer.
and Jamar hand grasp mechanical five-position dynamom­
eter (right).

lll: I l Illl'l l ll( (, \\\1, I I 1(,

COMMON AREAS OF
MENSURATION tll:!IILlI'1I11( (,\\\1'1117

I. Excursion of the chesl during inspiralion and CERVICAL SPINE EXTRINSIC

expiration MUSCULATURE WITH SPECIFIC
2. Upper-extremity circumference (brachium and ante­ NERVE ROOTS NOTED
brachium); measured in the noncontracled and con­
I. Deltoid (CS)
tracted state
2. Biceps (C6)
3. Lower-extremity circumferences ( thigh and calf);
3. Wrist extensors (C6)
measured in the noncontracted and contracted states
4. Triceps (C7)
4. Leg length (measured standing versus supine or
5. Wrist flexors (C7)
prone); differentiates a functional shan leg from an
6. Finger extensors (C7)
anatomic shan leg
7. Finger flexors (C8)
8. Finger abductors (T1)

During lhe stalic grip lcst, the duration of muscular contrac­

tion of each hand grip is 3 10 5 seconds. whereas during Lhe
REG maneuver. lhe hands alternate rapidly. resulting in a
�hortcr duration of each grip (Ics� than 1 .5 sccond� per grip) LlI:!IILlI'1 \ll( (,\\\tI1 11K
(Taylor c( al.2000).
A positil'e REG test i!<t obtained when REG l'Ocores
THORACOLUMBAR EXTRINSIC
arc greater than static grip scores. which indicates a l'!oub·
MUSCULATURE AND SPECIFIC
maximal or a feigned effort. A lIeglll;\'e REG test is obtained
ASSOCIATED NERVE ROOT
when slatic grip scores arc greater than REG scores. indical­
LEVElS
ing a maximal or a sincere eITon (Shechlman. Taylor. I. Hip flexors (L2-L3)
2002). 2. Knee extensors (L3-L4)
Cervical intrinsic muscle lesling relates to the cervical 3. Ankle extensors (L4--LS)
spine functions of flexion, extension, lateral flexion, and 4. Hip extensors (L4--LS)
rotation. 5. Knee nexors (L5-5 I)
Thoracolumbar imrinsic muscle function is associated 6. Ankle flexors ( 5I-52)
with trunk flexion. extension. lateral flexion. and rotation.
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 9

FIG. 1-9 From top to bottom, the Wanenberg pinwheel:

Boley two-point discrimination gauge: von Frey ancsthe­
,imctcr: Buck camel hair brush. pin. and neurologic hammer:
and u Serol China marker.
FIG. J-IO Aluminum alloy tuning forks. available in C-64.
C- 1 28. C-256. C-5 1 2. C- 1 024. C-2048. and C-4096 vibra­
tions. The lower-frequency luning forks are the usual choices
for bone vibration conduction studies.

Testing of the gross sensory modalities allows for evalu­

ation of the derl1latomcs involved in superficial and deep
sensations and proprioception (Fig. 1 -9).
The superficial scnsation� include light touch. pain. and
temperature. Light touch is mediated by the dorsal columns C4 C6 C4

and easily examined with a colton ball. Pilin receptors are

mediated by the lateral spinothalamic tracts and are tested
by a pinprick and hot and cold temperatures. Temperature.
or thermal scnsalian. mediated by the dorsal columns is
tested with warm ( not hot) and cool (not cold) tempera­
tures.
The deep sensat ions arc vibration and deep pressure per­
ception. The do"al columns of the spinal cord (Fig. 1 - 1 0)
mediate vibration. tested with a C-128 or lower-rrequency
luning rork. Deep pressure is ICMcd by squeezing any mus­
cular part of the body and is mediated in the dorsal
columns.
Proprioception. or joint po\ition �en\e. i� mediated by the
dorsal columns and can be tc;ted by having the patient point
to a particular part of the body while keeping the eyes
closed.

PAIN AND PATTERNS OF PAIN

Pain thal arises with activity and decreases with rest is l i kely C7
to ha\'c mechan ical causc�. The pain may be position depcn­ DERMATOMES MYOTOMES SCLEROTOMES
dent; most case\ of mechanical spinal pain have both a F I G. 1-1 1 Primary pallern� of pain originating in the �pioe:
provocative and palli:.ni\'e arc of l11otioo. derma tomes. myotol11e�. and sclerotomes. Demonstrated for
Spinal pain is the most difficult to differentially diagnose. lhe right upper extremity. (From Saidofl' DC. McDonough A: Cr;lj·
The three primary patterns are dermatogenous. myogenous. all 1H.lIl/l\'(/n ill therapf'lIlic in/(·n'f''''i(JI/.�, IIpper f'\lI"('milies, 51 Louis.
and sclcratogenous (Fig. I - I I). 1997. Moshy,)
10 CHAPTER I Principles i n Assessing Musculoskeletal Disorders
A dermatome is the area of sensation atlributed to a par­
ticular nerve root level. Dermatomal pain is often described
as sharp. stabbing, and well demarcated. It may result from
herniated discs, stretch injuries, or tumors.
Pain referral within muscular or fascial tissue is myoge­
nous pnin. Areas known as (rigger poiflls refer pain 10 distant
sites. Trigger points are evident in patients with myofascial
pain syndromes. Specific sites of tenderness that do not
result from referred pain are termed tellder poillfs. Tender
points develop in patients wilh varied sort-tissue, rheumatic.
and collagen-vascular disorders, such as systemic lupus ery­
thematosus and fibromyalgia.
Pain referred from somatic structures such as cartil age.
l igament, joint capsule, or bone often does not follow der­
matome patterns, as does nerve root pain. This pain is known
as sclera/agel/otis pain. Patients may describe this type of
pain as dull, achy, diffuse, and difficult to pinpoint. Sclera­
logenous pain is one of the morc common spinal pain
patterns.
Local Versus Referred Pain
Patients with referred pain often point to large generalized
areas. whereas patients with localized lesions can be more
specific. A patient complaining of unrelenting spinal pain.
demonstrating ful l , pain-free range of motion presents a
problem. The patient likely has either viscerosomatic pain,
which mandates further diagnostic te ting, or pain resulting
from a psychosocial cause. If referred pain from a diseased
organ system is mimicking a local orthopedic problem, the
examiner should not hesitate to order appropriate tests.
Every effort should be made to objectify the patient's
report of pain and discomfort. Measurement instruments
such as the visual analog scale (Fig. 1 - 12) are reliable and
valid for examining a patient's pain. The McGill Short
Form Questionnaire (Fig. 1 - 13) is helpful for pain mea­
surement in a clinical setting.
Pain is associated with a very high disability rate, sig­
nificantly affecting the three domains evaluated by the
Sheehan Disability Scale, which assesses patient functional
impairment in three domains: work impairment. social
impairment. and impainnent of family l i fe or home respon­
sibilities. Two further items gather data on patient-perceived
stress and social support.
On Ihe hoe below.
- place a mark mdlcalmg your pam le\el
o 10
F IG. 1 - 12 Visual analog scale for objective pain measure­
ment. (From Mulone TR. McPoil TG. Nit7. AJ: Orthopedic mill sports
p/n·Jical ,lteropy. cd 3. SI Loub. 1 997. Mo:.b).)
VITAL SIGNS
Vital signs include the brachial blood pressure, peripheral
pulse rate, respiration rate, height. weight, and vital capac­
ity. The instrumentation for these measurements includes
stethoscopes, spirometers, scales, tape measures. and blood
pressure cuffs (Fig. 1 - 1 4).
R ANGE OF MOTION
Of a l l the orthopedic tests that an examiner can perform on
a patient, none is more crucial than range-of-motion (ROM)
testing of the affected articulation. Range of motion testing
often reveals the origin of the patient's discomfort. because
movement may reproduce the pain. The patient is examined
symmetrically for aClive ROM of all the joints that may be
involved in the dysfunction or injury (Fig. 1 - 1 5). The exam­
iner then takes the patient through passi,'e ROM, evaluating
the e/ldleel (i.e., spri nginess) of the affected joint.
Any movable joint in the body, including the spine. can
be tested for ROM. ROM is assessed bilaterally by compar­
ing findings with a given set of normal values. Normal
values can vary dramatically, depending on the reference
source used, An examiner must exercise careful professional
judgment to ensure objectivity. Any ROM that is less than
normal may indicale or be the result of muscle spasm, sprain.
strain. joint subluxation, general anhrilic degeneration. post­
surgical condition. or obesity.
Recenll),. Childs and colleagues found in a clinical trial that
spinal stiffness was one of five predictors of which patients
wilh low back pain would respond favorably to a particular
physical lherapy manipulation. In their slUdy. they used a
manual assessment to grade the relative stiffness of the L4�
L5 and L5-S I joints. A palpable difference in the �tiffncs�
at these joints helped predict which patients were more
likely to respond favorably to manipulative therapy. Manual
palpation methods have been notoriousl), difficult to quan­
liry and suffer from a lack of objectivity. Interexaminer
OINT END-FEEL CATEGORIES
In passive joint motion assessment, the end-feel is
important. The accepted end-feel categories are:
Bone-to-bone: an abrupt halt to movement when two
hard surfaces meet
Capsular end-feel: a lealhery resistance to movement
with a slight amount of give at the very end of the
range
Springy block: a usually pathologic end-feel, gener­
ally representing an intraarticular displacement
Tissue approximation: no further joint movement
available
• Empty feel : usually pathologic
 CHAPTER I Principles in Assessing Musculoskeletal D isorders 1 1__

I
Check only one item for each category to describe your pain today.

2 3 4

1 Flickering 1 Jumping 1 Pricking t Sharp

2 Quivering 2 Flashing 2 Boring 2 Cutting
3 Pulsing 3 Shooting 3 Drilling 3 Lacerating
4 Throbbing 4 Stabbing
5 Beating 5 Lancinating
6 Pounding

5 6 7 8

1 Pinching 1 Tugging 1 Hot 1 Tingling

2 Pressing 2 Pulling 2 Burning 2 Itchy
3 Gnawing 3 Wrenching 3 Scalding 3 Smarting
4 Cramping 4 Saaring 4 Stinging
5 Crushing

9 10 11 12

1 Dull 1 Tender 1 Tiring 1 Sickening

2 Sore 2 Taut 2 Exhausting 2 Suffocating
3 Hurting 3 Rasping
4 Aching 4 Splitting
5 Heavy

13 14 15 16

1 Feartul 1 Punishing 1 Wretched 1 Annoying

2 Frightlul 2 Grueling 2 Blinding 2 Troublesome
3 Terrifying 3 Cruel 3 Miserable
4 Vicious 4 Intense
5 Killing 5 Unbearable

17 18 19 20

1 Spreading 1 Tight 1 Cool 1 Nagging

2 Radiating 2 Numb 2 Cold 2 Nauseating
3 Penetrating 3 Drawing 3 Freezing 3 Agonizing
4 Piercing 4 Squeezing 4 Dreadful
5 Tearing 5 Torturing

F I G . 1 - 1 3 McGill Short Form Pain QuesLionnaire. (From Malone TR. McPoil TG . Nitl AJ: Ortho·

pe(Jic (Il1d sports phYJiC(l/ ther(/I)): ed 3. S( Louis, 1 997. Mosby: rrom Mel7.acker R: The McGill Pain Quc�tion·

naire: major propenics and scoring methods. Pain 1:277. 1975.)

reliability or chiropractic palpation of segmental fixation is
typically poor to 5!light. Inlracxaminer reliability iii usually
rated :,omcwhat beuer. in the moderate to !o.ubMantial range.
depending on the experience of the exami ner. Similarly.
Miffness mcasures commonly used by physical therapi5!ts
show liulc interex3miner agreement. Childs and colleagues
were able to achicve acceptable reliability in the lumbar
mobility tClit they used by reducing the assc:,sment to three
level>: ( I ) hypomobilc. (2) normal. and (3) hypcrmobilc
(Owen, C( .1. 2(07).
joint and periarticular structures through their respective
arcs and end-range motions. Stability lesting involves stress­
ing ligamentous tissues and joint capsules (Fig. 1 - 1 6).
MUSCULAR ASSESSMENT
Movement resLrictions in a joint's passive ROM are nOI
exclusively articular. Muscular hypertonicity limits passive
movement and often occurs in association with articular
lesions Uoint dysfunction). Chronic joint problems are also
commonly associated with myofascilis.

STABILITY TESTING
Because clinical examination reveals the degree of ligamen­
tous or joint sprain, the examiner must be able to Lest accu­
rately for joint instability (Table 1 -2). Stability testing moves
CLINICAL L ABORATORY
For the examiner concemed with musculoskeletal disorders.
differential diagnosb becomes a chal lenge. Complete blood
12 CHAPTER I Principles i n Assessing Musculoskeletal Disorders

F I G . 1 - 1 5 From top to bottom, stainless steel goniometer

measures movement or joints rrom 0 to 180 degrees. Bubble
inclinometers measure the angular motion from 0 to 360
degrees. Finger or small joint goniometer measures the
movement or interphalangeal joints or fingers and toes.
Plastic radiographic goniometer provides standard orthope­
F IG . 1 - 1 4 Wall-mounted sphygmomanometer and stetho­ dic measurements of joint mOl ion and neutral position.
scope (Ie[t). Portable blood pressure curr (top right). Most
significant heart sounds occur in the frequency range of 200
to 500 Hz. bUl human auditory sensitivity is l i m i ted to those
,ounds below 1000 Hz. Stethoscopes ampliry the lower rre­
quencies (bollo/ll right).

lAB l 1 1-2

I N J U RED LIGAMENT REst DUAL FUNCTtON

Residual
Extent of Joint Motion, Residual Residual functional
Failure Sprain Damage· Subluxation Strength Functional Length Capacity

Mi nimal Finol degree Less thun onc lhird of None RClaincd or Nonnal Retained
fibers failed: slightly
includes Illost decreased
sprains with few to
some fibers failed.
Microlcars also exist.
Partial Second degree One-third to two- In geneml. minimal Marked Increased. still within Marked
lhirds ligament or no increased decrease. functiomll range compromise:
damage; significant motion. At risk for but may later act requires
damage. but pans Remaining fibers complete as a check rein healing to
of the ligament are in ligament re�ist failure rather than subtle regai n
sti l l functional . openi ng. control of joint function
Microtcars may exist. motions
Complete Third degree More than two-thirds Depcnw. on Little to none Lost Severely
to complete failure: !>CCondary None Lost compromised
continuity remains re\lrainlS or lost
In pan. Depcnd� on Lost
Conti nui ty lost and .!.econdary
gross separation restrai nts
between fibers

·E�limate of damnge i� often difficult: however. the different I) pc.. li"led can u,uall) be diffcrentiated. NOle: Antcrior IInci po..tcrior crucimc IC:lr.. commonly
c:tiSI with liule 10 no .Ihnonnlll laxilY. Thc c:taminalion for medial and Imeral 1igamentou<; injury is u..ually more :lecumte.
From Fcagin JA. edilor: Th(' ("rllcia/ ligaftlenl.\. New York. 1988. Chun:hill Li"ing�tonc.
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 13

FIG. 1-16 Lachman (eM of the anterior crucialc l igament. (From Scuderi GR. McCann PD. Bruno
PJ: SWJrI\' medicine: (Jrind/,Ies ofprimary C(l�. 51 Louis. 1 997. Mosby.)

Ll I�I II LlI' I I) I ( (, \\\l I I _'tl

RESISTED MUSCLE MOVEMENT LA BORATORY RESULTS

INTERPRETATIONS
In assessing muscle tissue, resisted movements are
the most revealing. Standard interpretations of For laboratory testing in orthopedic evaluations,
resisted muscle tesling movements include: results interpretation errors usually Involve one or
Painful and strong is equated with a m i nor lesion of four areas:
muscle or tendon. False-positive results
Painful and weak equates with a major lesion of the False-negative results
muscle or tendon. Measurcmcnt error
Painless and weak equates with neurologic injury or • Differences in groups of patients compared with indi­
complete rupture of the muscular auachment. vidual patients
Painless and strong is normaL

and urine tests can help determine a diagnosis. Diseases of

INDIVIDUAL BLOOD AND
the heart. liver. kidney. pancreas. and prostate can mimic
URINE TESTS
back pain of spinal origin.
Mo" laboratory te;ting has l imited utility for orthopedic
Acid Phosphates
diagnosis (Table 1 -3)_ As an example, in rheumatoid Dietary deficiencies in phosphorus arc rare but may be seen
arthritis, the diagnosis is often established from the history with alcoholism and malnutrition_ Low levels of phosphorus
and physical examination; for systemic lupus erythemato­ (hypophosphatemia) may also be caused by or associated
sus, from the laboratory test antinuclear antibody (ANA); with:
for gout, from a synovial nuid examination; and for anky� Hypercalcemia (high levels of calcium), especially as
losing spondylitis, from a radiograph. In common disorders a result of hyperparathyroidism
such as osteoarthritis. fibromyalgia, or muscular strains and Overuse of diuretics (drugs that encourage urination)
sprains. essentially no diagnostic role exists for laboratory Severe burns
tests except to exclude other diagnostic possibilities. Diabctic ketoacidosis ( after treatment)
The simplest orthopedic screen includes rheumatoid Hypothyroidism
arthritis factor. ANA, and uric acid, although more elaborate Hypokalemia (low levels of potassium)
screens arc available, which may include erythrocyte sedi­ Chronic antacid use
mentation rate. C-reactive protein. antislreptolysin-O liter. Rickets and osteomalacia (caused by vitamin-D defi­
protein clectrophore�is. quantitative immunoglobulins. and ciencies)
ANA subsets such as anti-Ro and anti-LA. anti-Sm. and Higher-than-nom,,1 levels of phosphorus (hyperphos­
anticentromcre antibodics. phatemia) may be caused by or associated with:
14 CHAPTER I Principles in Assessing Musculoskeletal Disorders

TAIlI F Ll

LABORATORY STUDIES USEFUL I N DIAGNOSING low BACK SYNDROMES

Test Measurement Low Back Implication

Complete blood count A measure of volume of circulating red May be diminished in systemic diseases (e.g.. neoplasm)
Hematocrit hemoglobin blood cells and in chronic spinal infections.
White blood count and differential Amount and type of circulating white Total white blood cell and shifts in differential Illay be
blood cells prescnt in spinal infections or occasionally in
spondyJoarthropalhics.
Sedimentation rate NonspecifiC test of inHammation Increased in spinal infections. may be increased in
neoplasms and spondylo3nhropalhies.
Chemistry A measure of circulating calcium and Calcium is elevated in hyperp.trathyroidism, may be
Calcium phosphorus elevated with primary and secondary osseous tumors.
Phosphoru� alterations in the distribution of calcium and phosphorus
accompany many metabolic disorder!\: but arc norma.l in
osteoporosis.
Alkaline pho�phi1tase Enzyme associated with bone rannalian; May be elevated in primary or secondary osseous
therefore: elevation implies increased neoplasllls.
bone formalion.
Acid phosphatase An enzyme associated with tumors Increased in prostatic tumors.
metastatic to bonc
Serum proteins (albumin globulin Measurement of amount and type Elevations of one fraction of globulin are associated with
protein electrophoresis) protcin circulating multiple myeloma.
HLA·B27 antigen A circulating antigen Usually individuals with spondyloarthropaLhies arc HLA·
827 positive. NOle 6·8% of men have this antigen and
therefore its presence is not confinnaLory of a
spondyloarthropathy.

fiLA. Human leukocyte antigen.

Adaptcd from Pope ML: OCl"II{J(J/;OIUll low back paill. asseSSIllt'/It, IY'I!(I/f1U.'f/I (lnd prcl'elll{(}I/. SI Louis. 1991, Mosby.

• Kidney failure
Hypoparathyroidism (underactive parathyroid gland)
Diabetic ketoacidosis (when first seen)
Phosphate supplementation
Alkaline Phosphatase
Increased serum alkaline phosphatase is seen in states of
increased osteoblaSlic activity (hyperparathyroidism, osteo­
malacia. primary and mctastatic neoplasms), hepatobiliary
diseases charaClCriL.ed by some degree of inlra- or extrahe­
patic cholestasis. and in sepsis. chronic inHammatory bowel
disease, and thyrotoxicosis. Isoenzyme determination may
help detennine the organ or tissue responsible for an alkaline
phosphatase elevation.
Decreased serum alkaline phosphatase may not be clini­
cally significant. However, decreased serum levels have
been observed in hypothyroidism. scurvy. kwashiorkor.
achondroplastic dwarfism, deposition of radioactive materi­
als in bone, and in the rare genetic condition hypophospha­
tasia.
A mylase
In acute pancreatitis, amylase in the blood increases (often
to four to six times higher than the highest reference value,
sometimes called the upper limit of normal). The
occurs within 12 hours of injury to the pancreas and gener­
ally remains elevated until the cause is successfully treated.
Then the amylase values will return to normal in a few days.
In chronic pancreatitis, amylase levels will initially be mod­
erately elevated bul often decrease over time with progres­
sive pancreas damage.
Amylase levels may also be significantly increased in
patients with pancreatic duct obstruction. cancer of the pan­
creas, and gallbladder allacks. Urine and blood amylase
levels may also be elevated wilh a variety of other condi­
tions, such as ovarian cancer, lung cancer, tubal pregnancy,
mumps, intestinal obstruction, or perforated ulcer, but
amylase tests are not generally used to diagnose or Illonilor
these disorders. Decreased blood and urine amylase levels
may indicate permanent damage to the amylase-producing
cells in the pancreas. Increased blood amylase levels with
normal to low urine amylase levels may indicate decreased
kidney function or the presence of a macroamylase. a benign
complex of amylase and other proteins that accumulates in
the blood.
Given that reference values for amylase vary from labo­
ratory to laboratory, depending on the test method used, no
universally accepted numberexisls that can be called nornlal
or high.
Anti-Nuclear A ntibody
increase Anti-nuclear antibody (ANA) tests are performed using dif­
ferent assays (indirect immunoHuorescence microscopy or
by enzyme linked immunoabsorbent assay). and results are
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
reported as a liler with a particular type o f immunofluores­
cence pattern (when positive). Low-level titers are consid­
ered negative, whereas increased lilers, such as I : 320, are
positive and indicate an elevated concentration of ANAs.
ANA shows up on indirect immunofluorescence as fluo­
rescent patterns in cells that arc fixed to a slide that is
evaluated under a microscope. Different patterns are associ­
ated with a variety of autoimmune disorders. Some of the
morc common patlems include:
Homogenous (diffuse)-associated with systemic lupus
erythematosus (SLE) and mixed connective tissue
disease
Speckled-associated with SLE. Sjogren syndrome.
sclerodemta. polymyositis. rheumatoid arthritis. and
mixed connective tissue disease
Nucleolar-associated with scleroderma and poly­
myositis
Outline pattern (peripheraJ)-associated with SLE
An example of a positive resul t might be positive a/
J : 320 ,Ii/wioll ",i,h a homoge"ous pallem.
A positive ANA test result may suggest an autoimmune
disease, but further specific testing is required to assist in
making a final diagnosis. ANA test results can be positive
in people without any known autoimmune disease. Although
this finding is not common. the frequency of a false positive
ANA result increases as people get older.
Approximately 95% of patients with SLE have a positive
ANA test result. If a patient also has symptoms of SLE. such
as anhritis. a rash. and autoimmune thrombocytopenia. then
the patient probably has SLE. In cases such as these. a
positive ANA result can be useful to support the SLE diag­
nosis. Two subset tests for specific types of autoantibodies.
such as anti-dsDNA and anti-Sm. may be ordered to help
confimt that the condition is SLE.
A positive ANA can also mean that the patient has drug­
induced lUpus. This condition is associated with the devel­
opment of aUloanlibodies to histones, which are water-soluble
proteins rich in the amino acids lysine and arginine. An anti·
histone test may be ordered to support the diagnosis of
drug-induced lupus.
Other conditions in which a positive ANA test result may
be seen include:
Sjogren syndrome: Between 40% and 70% of patients
with this condition have a positive ANA test result.
Even though this finding supports the diagnosis, a
negative result does not rule it out. The examiner may
want to test for two subsets of ANA: anti-SS-A (Ro) and
anti-SS-B (La). The frequency of autoantibodies to
SSA in patients with SjOgren syndrome can be 90% or
greater.
Scleroderma: Approximately 60% to 90% of patients
with scleroderma have a positive ANA finding. In patients
who may have this condition. ANA subset tests can help
distinguish two forms of the disease. l imited versus
diffuse. The diffuse form is more severe. Limited disease
is most closely associaled with the anticentromere patlem
of ANA staining (and the anticentromere test), whereas
15
the diffuse form is associated with autoantibodies to the
anti-ScI-70.
A positive result on the ANA may also show up in
patients with Raynaud disease. rheumatoid arthritis. der­
matomyosilis, mixed connective tissue disease. and other
autoimmune conditions.
Because symptoms may come and go. months or years
may be required to show a pattent that might suggest SLE
or any of the other autoimmune diseases.
A negative ANA result makes SLE an unlikely diagnosis.
Immediately repeating a negative ANA test is not usually
necessary: however. because of the episodic nature of auto­
immune diseases. repeating the ANA test at a future date
may be worthwhile.
Aside from rare cases. further autoantibody (subset)
testing is not necessary if a patient has a negative ANA
result.
Antislrepto(ysin-O Titer
Antistreptolysin-O ( A SO) titer test results can be reported
in several different ways: however. the interpretation is gen­
erally the same: The higher the result is. the more antibody
that is present in the blood (unless a titer is perfonned. which
is a ratio and therefore is interpreted differently).
The ASO antibody is either absent or present in very
low concentrations in patients who have not had a recent
streptococcal (strep) infection. Antibodies are produced
approximately a week to a month after the initial slrep infec­
tion. ASO levels peak at approximately 4 to 6 weeks after
the illness and then taper off but may remain at detectible
levels for several months after the strep infection has
resolved.
If the test is negative. or if ASO is present in very low
concentrations. then the patient 1110St likely has not had a
recent strep infection. especially if a sample taken 1 0 to 1 4
days later is also negative or minimal.
If the ASO level is high or is rising. then a recent strep
infection has likely occurred. ASO levels that are initially
high and then decline suggest that an infection has occurred
and may be resolving.
The ASO test does not predict whether complications
will occur after a strep infection, nor do they predict the
severity of the disease. If symptoms of rheumatic fever or
glomerulonephritis are present, an elevated ASO level may
be used to confirm the diagnosis.
Bence-Jones Protein
A Bence-Jones protein is a monoclonal globulin protein
found in the blood or urine. The isolated finding of a Bence­
Jones protein is known as monoclonal gammopathy of
uncertain significance. Finding this protein in the context of
end-organ manifestations such as renal failure, lytic bone
disease. or anemia. or large numbers of plasma cells in the
bone marrow of patients can be diagnostic of multiple
myeloma.
The proteins are antibody immunoglobulin-free light
chains (paraproteins) and are produced by neoplastic plasma
16 C HAPTER I Principles i n Assessing M usculoskelelal Disorders
cells. The lighl chains can be delecled by healing or eleclro­
phoresis of concentrated urine. Light chains precipitate
when heated 10 50· 10 60· C and re-dissolve aI 90· 10 100·
C. These tests arc essential in patients who may bave Bence­
Jones proteins in their urine because these proteins do not
react with the reagents normally used in urinalysis dipsticks.
This circumstance lead� to false-negative results in people
with Bence-Jones proteins in their urine undergoing stan­
dard urinaly�is. Various rarer conditions can produce Bence­
Jones proteins. such as Waldenstrom macroglobulinemia
and other mal ignancies.
Bilirubin
VeM.'boT/u
Excessive bilirubin kills developing brain cells in infanls
and may cause mental retardation. physical abnonnalities,
or blindness. Bilirubin in newborns must not become 100
high. When Ihe level of bilirubin is above a crilical lhresh­
old, special treatments arc initiated to lower it. An excessive
bilirubin level may resull from Ihe breakdown of red blood
cells ( R BCs) caused by Rh blood Iyping incompatibililY.
(The mOlher is Rh negalive I Rh-I. lhe father is Rh posilive
I Rh+l. and Ihe felUs is Rh+: Ihe mOlher develops antibodies
again;! Ihe newbom's RBCs. which are destroyed.)
Idl///.\ alld Childrell
Bi lirubin level� can be used (0 idcIHify liver damage or
disease or to monitor the progression of jaundice. A conju­
gated bilirubin that is elevated may indicate some kind of
blockage of Ihe liver or bile duCI. hepmilis. lrauma 10 lhe
l iver, a drug reaction. or long-Icnn alcohol abuse. Inherited
di,orders caused by abnonnal bilirubin melabolism (Gilbert,
ROlOr. Dubin·Johnson. or Crigler·Najjar syndromes) may
also cause increased levels.
Blood Urea Nitrogen
Increased blood urea nilrogen (BUN) levels suggesl impaired
kidney function. This elevation may be caused by acute or
chronic kidney disease. damage. or failure; i t may also be
caused by a condilion Ihal resulls in decreased blood How
(0 the kidneys, slich as congestive heart failure, shock. stress,
recent heart attack, or severe bums; to conditions that cause
Ob!<llflictiOIl of urine now: or to dchydrmion.
B U N concentrations may be elevated in the setting of
excessive prolein catabolism (breakdown). significanlly
i ncrea!>.ed protein in the diet. or ga!>.lIointestinal bleeding
(becau,e of Ihe prolein, presenl in the blood).
Low BUN levels are not common and are not usually a
cause for concern. They may be seen in severe liver disease,
malnutrition. and sometimes when a patient is overhydnlled
(excessive nuid volume): bUI Ihe B U N lesl is nol normally
used to diagnose or monitor these conditions.
Both decreased and increased B U N concentrations may
be seen during a normal pregnancy.
I f one kidncy is fully funclional, B U N concenlralions
may be nonnal even when significant dysfunction is presem
in Ihe olher kidney.
Calcium
A nonnal calcium result with other nom13l laboratory results
means lhal Ihe patient has no problems with calcium melab·
olism (use by the body).
Because approximately one half of the calcium in Ihe
blood is bound by albumin (a prolein). Ihese IwO lesls are
usually ordered logelher. Calcium values musl be inlerpreled
in combination with albumin 10 delenlline if the calcium
concentration of serum is appropriate. As albumin level�
rise, calcium rises as well. and vice versa.
A high calcium level is called hypercalcemia, requiring
trearment for the underlying condition. Hypercalcemia is
usually caused by:
Hyperparathyroidism ( i ncrease in paralhyroid gland
funclion): This condilion is usually caused by a benign
lumor on Ihe paralhyroid gland. This fonn of hypercal­
cemia is usually mild and can be present for many years
before being nOliced.
Cancer: Cancer can cause hypercalccmia when it �preads
to the bones, which releases calcium into the blood. or
when cancer causes a hormone similar to parathyroid
hormone to increase calcium levels.
Olher causes of hypercalcemia include:
Hyperthyroidism
Sarcoidosis
Tuberculosis
Bone break!>. combined with bed rest or not moving
for a long periods
Excess vitamin D intake
Kidney lransplantation
High prolein levels (e.g .. if a lourniquel is used for 100
long while blood is collecled)
In this case, free or ionized calcium remains normal. High
levels of ionized calcium occur with all the conditions previ­
ously menlioned. excepl high prolein levels.
Low calcium levels. called hypocalcemia. mean that the
patient has insufficieJ1l calcium i n the blood or Ihal Ihe
patient has insufficienl prolein in Ihe blood. The moS!
common cause of low total calcium is low protein levels.
especially low albumin. When low prolein i< Ihe problem.
the ionized calcium level remains normal.
Low calcium. known as hypocalcemia, is caused by many
conditions:
Low prolein levels
Underaclive paralhyroid gland ( hypoparalhyroidism)
Decreased dietary imake of calcium
Decreased levels of vitamin 0
Magnesium deficiency
Excessive phosphorus
Acute inflammation of the pancreajo,
Chronic renal failure
Calcium ions becoming bound 10 prole in (alkalosis)
Bone disease
Malnutrition
Alcoholism
Causes of low ionized calcium Icvels include all of these
condition except low protein levels.
 C HAPTER I Principles in Assessing Musculoskeletal Disorde"
Chloride
Increased levels of chloride (hyperch/oremia) usually indi­
cate dehydration, but high levels can also occur with any
other problem that causes high blood sodium. Hyperchlore­
mia also occurs when excessive base is lost from the body
( producing metabolic acidosis) or when a person hyperven­
tilates (causing respiratory alkalosis).
Decreased levels of chloride (hypoch/oremia) occur with
any disorder that causes low blood sodium. Hypochloremia
also occurs with prolonged vomiting or gastric suction.
chronic diarrhea. emphysema or other chronic lung disease
(causing respiratory acidosis), and with loss of acid from the
body (causing metabolic alkalosis).
Cholesterol
In a routine setling in which testing is perfonncd to screen
for risk factors, the test results arc grouped in three catego­
ries of risk:
Desirable: A cholesterol level below 200 mg/dL
(5. 1 8 mmol/L) is considered desirable and reflects a low
risk of heart disease.
Borderline high: A cholesterol level of 200 to 240 mg/dL
(5. 1 8-6.22 mmol/L) is considered 10 reflect moderate
risk.
High risk: A cholesterol level above 240 mg/dL
(6.22 mmol/L) is considered high risk.
Creatinine
Increased creatinine levels in the blood suggest diseases
or conditions that affect kidney function, including the
fol lowing:
Damage to or swelling of blood vessels in the kidneys
(glomerulonephritis) caused by. for example, infection or
autoimmune diseases
Bacterial infection of the kidneys (pyelonephritis)
Death of cells in the kidneys' small tubes (acute tubular
necrosis) caused. for example, by drugs or toxins
Prostate disease, kidney stone. or other causes of urinary
tracl obstruction
Reduced blood flow to the kidney caused by shock, dehy­
drmion. congestive hean failure. atherosclerosis, or com­
plications of diabetes
Creatinine can also increase temporarily as a result of
muscle injury. Low levels of creatinine are not common and
are not usually a cause for concern and can be seen with
conditions that result in decreased muscle mass. Creatinine
levels are generally slightly lower during pregnancy.
Creatinine Phosphokinase
A high creatinine phosphokinase (CK) level, or one that
goes up from the first to the second or later samples, gener­
ally indicales some damage to the heart or other muscles; it
can also indicate that the patient's muscles have experienced
heavy use. If the patient has experienced a heart allack and
the CK is high, a more specific test (troponin or CK-MB)
should be ordered to determine if the patient's heart is
damaged.
17
Glucose
High levels of glucose most frequently indicate diabetes, but
many other diseases and conditions can also cause elevated
glucose. The following information summarizes the meaning
of the test results. These points are based on the clinical
practice recommendations of the American Diabetes Asso­
ciation (Table 1 -4).
Some of the other diseases and conditions that can result
in elevated glucose levels include:
• Acromegaly
Acute stress (response to trauma, hean attack, and
stroke for instance)
• Chronic renal failure
Cushing syndrome
Drugs (e.g., conicosteroids, tricyclic antidepressants.
diuretics, epinephrine, estrogens [birth control pills
and hormone replacement medications I, lithium, phe­
nytoin [ Dilantin"'" salicylates)
Excessive food intake
Hyperthyroidism
Pancreatic cancer
Pancreatitis
Low to nondetectible urine glucose results are considered
normal. Anything that raises blood glucose levels also has
the potential to elevate urine glucose levels. Increased urine
glucose levels may be seen with medications such as estro­
gens and chloral hydrate and with some forms of renal
disease.
Moderately increased levels may be seen with prediabe­
tes. This condition, if left untreated. often leads to type 2
diabetes.
Low glucose levels (hypoglycemia) are also seen
with:
Adrenal insufficiency
Drinking alcohol
Drugs (e.g., acetaminophen, anabolic ;tcroids)
Extensive liver disease
Hypopituitarism
• Hypothyroidism
Insulin overdose
Insulinomas (insulin-producing pancreatic tumors)
Starvation
Heavy Metal Screens
Heavy metals are increasingly responsible for the produc­
tion of free radicals. as well as undermining the illlernal
ell v;romnellf and body chemistry. The main concern is not
so much the type of metal that may be detected but rather if
metals in their ionic form are present. Chemical analyses can
establish the exposure to excessive amounts of toxic sub­
stances. Many analytical procedures can be performed if the
problem warrants me investment of time and the client is
willing to pay for the procedure. Although screening samples
for cenain groups of chemicals is possible. analyzing for
everything or checking for poisons is not feasible. Heavy
metals include arsenic. cadmium. calcium. cobalt, copper,
18 C HAPTER I Principles i n Assessing Musculoskeletal Disorders

TAIl L E 1 -4

SUMMARY or GLUCOSE TOLERANCE TESTS AND I NTERPRETATtONS

Fasting Blood Glucose

From 70 to 99 rng/dL £3.9 to 5.5 mmol/L) Normal glucose tolerance
From 1 00 LO 125 OlgldL {5.6 to 6.9 mmoVL) Impaired fasting glucose (prediabclc..'iI)
1 26 mgldL (7.0 mmol/L) and above on more than one tcsling occasion Diabetes

Oral Glucose Tolerance Test (OG1T) [except pregnancy] (2 hours after a 75-gram glucose drink)
Lc�s Lhan 1 40 mgldL (7.8 mmollL) Nonllai glucose tolerance
From 140 10 200 mgldL (7.8 10 1 1 . 1 mmollL) Impaired glucose lo\cram:e (pre-diabetes)
Over 200 mgldL ( 1 1 . 1 Illmul/L) on more limn one testing occasion Diabetes

Gestational Diabetes Screening: Glucose Challenge Test (1 hour after a 50-gram glucose drink)
Less than 140* mg/dL (7.8 mmoVL) Normal glucose tolerance
1 40· mgldL (7.8 rnmollL) and over Abnormal. needs OGTI (�ce below)

Gestational Diabetes Diagnoslic: OGT'I' ( I OO-gram glucose drink)

Fu!.ting· 95 mg/dL (5.3 mmolfL)
I hour after glucose load 180 mgidL ( 1 0.0 mmollL)
2 hours after glucose load' 155 IllgidL (8.6 mmollL)
3 hours after glucose load' 140 mgidL (7.8 mmol/L)

"'Some use ,\ cUloff of > I JO mg/LIL (7.2 mmollL) bccau..c that identitic!; 901H of women with ge�w.lional diuOOlc.... compureel to SOIk idcmilicd using the
lhreshold or >140 mgldL (7.8 mmoIlL).
If two or more val ue... :u-c ubove the criteria. gestutionul diabetes is diagnosed.
A 75-gr:lI11 glucose load may be used. although thh method is not as v.cll validated as the IOO-gram OGTI: the 3-hour ..ample b not dr:lV.n iPS gram... is
u�cll.

cyanide. f1 uoride, iron, lead, magnesium,
mercury, molybdenum, phosphorus, potassium, selenium.
sodium, and zinc.
Hematocrit
Decreased hematocrit indicates anemia, such as that caused
by iron deficiency or other deficiencies. Further testing
Illay be necessary to detennine the exact cause of the
anemia.
Other conditions that can result in a low hematocrit
include vitamin or mineral deficiencies, recent bleeding, cir­
rhosis of the liver, and malignancies.
The 1l10�t common cause of increased hematocrit is dehy­
dration, and with adequate fluid intake, the hematocrit
returns to normal. However, increased levels may reflect a
condition called pol.\'cythemia \Iera-thm is, when a peniOll
ha, more than the normal number of RBCs. Increa,ed hema­
tocrit can be caused by a problem with the bone marrow or.
more commonly. as compensation for inadequate lung func­
tion (the bone marrow manufacLUres more RBCs to carry
enough oxygen throughout the body).
Hemoglobin
Normal values in an adult nre 1 2 to 1 8 gJdL ( 1 00 mm/dL)
of blood. Above-nonnal hemoglobin levels may be the result
or:
Dehydration
Excessive production of RBCs in the bone marrow
Severe lung disease
Several other conditions
manganese. Below-normal hemoglobin levels may lead to anemia
that can be the result of:
Iron deficiency or deficiencies in essential vitamins of
other elements such as vitamin B 1 2, folate. vitamin
B6
• lnherited hemoglobin defects. such as sickle cell
anemia or thalassemias
Other inherited derects arfecting the RBCs
CilThosis of the liver (during which the liver becomes
scarred)
Excessive bleeding
Excessive destruction of RBCs
Kidney disease
• Other chronic illnesses
Bone marrow failure or aplastic anemia
Cancers lhat afrect the bone marrow
Human Leukocyte Antigen-B27
Human leukocyte antigen ( H LA)-B27 will be present or
absent. I f it is present. then the HLA-B27 antigen ( protein
structure) exists on the surface or the body's while blood
cell> (WBCs) ,uld nucleated cells. I f a patient has HLA-B27
and has symptoms such as chronic pain. innammalion. and
degenerative changes to his bones (as seen on X-ray exam­
ination), then it supports a diagnosis of ankylosing spondy­
litis (AS), Reiter syndrome. or another autoimmune disorder
thal is a'Sociated with the presence or HLA-B27. This cir­
cumstance is especially true ir the patient is young. male
gender. and ir the patient experienced the first symptoms
before the age of -10.
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
The presence o f HLA-B27 may also seen w i t h other
autoimmune conditions huch as:
Isolated acute anterior uveitis
• Undifferentiated spondyloarthropathies
• Entcropathic synovitis
I f HLA-B27 is not present. then the symptoms arc likely
the result of an HLA-B27-associated autoimmune disorder.
( Exceptions to this rule, however. arc approxi mately 10% of
patients with AS and 40% to 50% of those with Reiter syn­
drome w i l l be negative for HLA-B27.)
At this time. identifying the presence of HLA-B27 does
not predict the likel ihood of developing an autoimmune
disease. If a patient does have an associated disorder. the
presence of HLA-B27 cannot be used to tell which disease
is present, how quickly it will progress, its severity. prog­
nosis. or the degree of organ involvement.
Lactic Dehydrogenase Compression Test n
Elevated levels of lactic dehydrogenase (LDH) and changes
in the ratio of the LDH isocl1tymcs usually indicalc some
type of tissue damage. LDH levels w i l l usually rise as the
cellular destruction begins. peak after some time period. and
then begin to fal l . For instance. when someone has a heart
allack, blood levels of total LDH will rise within 24 to 48
hour;, peak in 2 to 3 days, and return to normal in 1 0 to 1 4
days.
Elevated levels of LDI-I may be seen with:
Cerebrovascular accident (CVA. stroke)
Drugs (c.g .. anesthetics, aspirin, narcotics. procain­
amide_ alcohol)
Hemolytic anemia
Pernicious anemias ( megaloblastic anemias)
I nfectiolls mononucleosis
I ntestinal and pul monary infarction (tissue deat h )
Kidney disease
Liver disease
Muscular dystrophy
Pancreatitis
Some cancers
With .!tome chronic and progressive conditions. and
;ol11e drugs. moderately elevated LDH levels may
per�isl.
Low and normal levels of LDH do not usually indicate a
problem. Low levels are sometimes seen when a patient
ingests large amounts of ascorbic acid (vitamin C).
Latex Agglutination
Various rapid tests identifying bacterial antigen from body
nuids are becoming increasingly avail able. One of these
technique;. latex agglutination. is frequently used 10 test
cerebrospinal fluid in chi ldren being eval uated for possible
meningitis. Early diagnosis of meningitis can lead to prompt
treatment.
Leucine Aminopeptidase
Serum leucine aminopeptidase determination is a useful
screening procedure for hepatobi l iary disease in jaundiced
19
and unjaundiced patients. Values under 1 000 units arc of no
help in the differential diagnosis of jaundice, but values
above 1000 units are highly indicative of b i liary ob;truction.
The differentiation of intra- from extrahepatic obstruction,
as well as of malignant from benign jaundice. cannot gener­
a l l y be e;tablished by this single tesl.
Lipase
In acute pancreatitis, l i pase levels are freq uently very high,
often 5 to 1 0 times higher than the highest reference value
(often cal led the upper limit of normal). In acute pancreati­
tis. l i pase concentrations rise within 24 to 48 hours of an
acute pancremic atlack and may remain elevated for approx­
imately 5 to 7 days. Concentrations may also be increased
with pancreatic duct obstruction. pancreatic cancer. and
other pancreatic diseases.
Moderately increased l ipa;e values may occur in other
conditions such as kidney disease (caused by decreased
clearance from the blood), salivary gland infl ammation, a
bowel obstruction, or peptic ulcer dise,,-,e, although the
l ipase test is not nOnllally lIsed to monitor these conditions.
Decreased li pase levels may indicate pennanent damage to
the l i pase-producing cells in the pancreas.
lipidS
The lipid profile includes IOtal cholesterol, high-density
l ipoprotein ( H D L ) cholesterol (often called good choles­
terol). low-density l ipoprotein (LDL) cholesterol (often
called bad cholesterol). and triglycerides. The report w i l l
sometimes includc additional calcu lated valucs such a'\
H DULDL ratio or a risk score based on lipid profile results,
age. sex, and other risk factors.
A normal level for fasting triglycerides is less than
1 50 mgldL ( 1 .70 mmoI/L). Having high triglycerides
without also having high cholesterol is unusual. Most treat­
ments for heart disease risk will be aimed at lowering LDL
cholesterol. However, the type of treatment used to lower
LDL cholesterol may differ depending on whether triglyc­
erides are high or normal.
Triglycerides that arc very high (greater than 1 000 mgldl
1 1 1 .30 mmol/L]) increases the risk of developing pancreati­
tis. Treatment to lower trig lycerides should be started a;
soon as possible.
Lupus Erythematosus Cell Prep
The lupus erythematosus (LE) cell prep was the primary
diagnosis of SLE for nearly 50 years. having a sensitivity of
nearly 50%. This test has been replaced by a more sensitive
test. ANA. which measures the binding of a patient's serum
antibodies to HEp-2 cell nuclei.
The results of each of the lupus anticoagulant te", lead
either toward or away from the likeli hood of having a lupus
anticoagulant. Although the tests performed may vary. they
u,u,lIly begin with a prolonged panial thromboplastin time
( PTT ) .
If the PTT or lupus anticoagulant (LA)-PTT is prolonged,
and mixing it with normal pooled plasma does not correct
20 C HAPTER I Principles in Assessing Musculoskeletal Disorders

the result, then an inhibitor is likely present. If the pro­ Chronic antacid use
longed test corrects when phospholipid is added, then a Rickets and osteomalacia (caused by vitamin-D
lupus anticoagulant is likely present. (After heparin con­ deficiencies)
tamination. a lupus 3micoagulalll is the most common H igher-than-normal levels of phosphorus ( hyperphos­
reason for a prolonged PTr.) phatemia) may be caused by or associated with:
If the PTr is not prolonged, a lupus anticoagulant may Kidney failure
not be present, the test reagents may contain too much Hypoparathyroidism (underactive parathyroid gland)
phospholipid. or the test may not be sufficiently sensitive •
Diabetic ketoacidosis (when first seen)
to pick up the lupus anticoagulant. The LA-sensitive PTr Phosphate supplementation
may need to be performed.
If a dilute Russell viper venom time or modified Russell Potassium
viper venom time test is prolonged and does not correct Increased potassium levels indicate hyperkalemia. Increased
when mixed with normal pooled plasma but does corrCCl levels may also indicate the following health conditions:
with Ihe addition of phospholipids, then a phospholipid Excessive dietary potassium intake ( Fruits are par­
antibody is likely present. ticularly high in potassium; therefore, excessive
If a thrombin time lest is nonnal, then heparin contamina­ intake of fruits or juices may contribute to high
tion is excluded. potassium.)
If a fibrinogen test is nonnal. then fibrinogen is likely Excessive imrdvenous potassium intake
sufficient for normal clot formation. Acute or chronic kidney failure
Other tests that may be performed 10 help confinn the Addison disease
diagnosis of a lupus anticoagulant include: Hypoaldosteronism
Platelet neutralization (This test uses platelets as a Injury to tissue
source of phospholipids.) Infection
Hexagonal ( I I ) phase phospholipid assay (Staclot-LA Diabetes
test) Dehydration
Kaolin clotting time Cenain drugs can also cause hyperkalemia in a small
Tissue thromboplastin inhibition lest percentage of patients. Among these drugs are nonsteroidal
"'
Venereal Disease Research Laboratory (VORL) or untiinnammatory drugs (e.g., Advil"'. MOlIin , Nuprin- ).
rapid plasma reagin (RPR) (These tests are used to beta-blockers (e.g.. propranolol atenolol). angiotensin­
detect syphilis. Their reagents arc made of cardiolipin converting enzyme inhibitors (e.g .. captopril. enulapril.
and they may give a false positive result for both lisinopril). and potassium-sparing diuretics (e.g .• triam­
anlicardiolipin antibodies and for lupus anticoagu­ terene. amiloride. spironolactone).
lant.) Decreased levels of potassium indicate hypokalemia.
Coagulation factors (These tests may be ordered to Decreased levels may occur in several conditions. particu­
rule out factor deficiencies that may cause a prolonged larly:
PTr and bleeding episodes.) Dehydration
Prothrombin lime •
Vomiting
Other tests that may be performed in addition to lupus Diarrhea
anticoagulant testing include: Deficient potassium intake ( rare)
Anticardiolipin and anti-beta2-glycoprotein I antibod­
ies to check for anti phospholipid syndrome Protein-Bound Iodine
Platelet count (Mild to moderate thrombocytopenia is Iodine binds to protein. mainly thyroxin. in the plasma. The
often seen a10ng with the lupus anticoagulant and may thyroid honnone is precipitated by protein-denaturing
be caused by anticoagulant I heparinl therapy.) agents. and the amount of iodine in a protein precipitate
generally indicates the amount of thyroid hormone present
Phosphorus and is thus an index of thyroid activity. Various values are
Dietary deficiencies in phosphorus are rare but may be seen given for thyroid function: hypothyroidism. 0 to 3.5 mcg!
with alcoholism and malnutrition. Low levels of phosphorus mL of protein-bound iodine: euthyroidism. 3.5 to 8.0 g!mL:
(hypophosphatemia) may also be caused by or associated hyperthyroidism, values higher than 8 mcg!mL.
with:
•
Hypercalcemia (high levels of calcium) especially as Red Blood Cell Count
a result of hyperparathyroidism A high RBC count may indicate congenital heart disease.
•
Overu�e of diuretics (drugs that encourage urination) dehydration. obstructive lung disease. or bone marrow
Severe bUnls overproduction. A high RBC count is also seen in bela­
Diabetic ketoacidosis (after treatment) thalassemia trait, a benign condition with little or no anemia.
Hypothyroidism A low RBC count may indicate anemia. bleeding. kidney
Hypokalemia (low levels of potassium) disease. bone marrow failure (for instance. from radiation or
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
a tumor). malnutrition. o r other call�es. A l o w count may
abo indicate nutritional deficiencies of iron. foJ:.uc. vitamin
B 12, and vitamin 86.
Rheumatoid A rthritis Factor (RA Latex) Test
A mpid latex .Iide agglutination te,t ror the qualitative and
semi-quantitative determ ination of rheumatoid arthritis
factor in human serum. The presence of these aUlOalllibodies
to human immunoglobu l i n G (IgG ) is a userul diagnostic
tool ror aClive rheumHloid arthrilis ( R A J becau,e high li tres
indicate severe disease.
Serum Glutamate Oxaloacetale Transaminase
Very high levels or aspanate aminOlransremse (AST) ( more
than 10 Lime!' the highcM nOfmal lcvel) are usually the result
of acute hepatitis. oflen caw.,cd by a virus infection. In acute
hepat ili,. AST level> u,ually stay high ror approx imately I
to 2 months but can take as long as 3 to 6 l110lllhs to return
to normal. I n chronic hepatitis. AST levels are usually not
a:-. high as they arc in acute hepat itis. often les� than four
time� the highe�t normal level. I n chronic hepatitis. AST
onen varies between nonnal and slightly increased: there­
fore. examiner.!> w i l l typically order the test frequently to
determ ine the pattem.
In '!'ol1le di seases of the liver. especially when the bile
duct� are blocked. or with cirrhosis and cenain cancers of
the liver. AST may be close to normal. but it i l1crease� more
often than alanine aminotnll1,remse (ALT). When liver
damage is the result of alcohol, AST often increases much
more than A LT. (This pattem is seen with a few Olher liver
dise,,,es.) AST i, also increased arter heart anacks and wilh
mu�cle injury. usually to a much greater degree than is
A LT.
Serum Ionized Calcium
Blood calcium is tested to screen for. di agnose. and monitor
a range of conditions relating to the bones. hean, nerves.
kidneys. and leelh. Blood calcium level> do not directly lell
how much calcium i s in the bones. but ralher, how much
calcium is circulating i n lhe blood.
A total calcium level is often measured as pan of health
screen ing. It is incl uded in the comprehensive metabolic
panel (CMP) and the basic metabolic panel ( B M P)-groups
of tests that are performed together to di agnose or monitor
a variety of conditions. When an abnormal total calcium
result is obtai ned. it i s viewed as an indicator or some kind
of underlying problem. To help diagnose the underlying
problem. additional tests are often done to measure ionized
calcium. urine calcium, phosphorous, magnesium. vitamin
D. and paralhyroid hormone (PTH). Parathyroid hormone
and vitamin D arc responsible for maintaining calcium con­
centrations in the blood within a narrow range of values.
Measuring calcium and PTH together can help determine
whether the parathyroid gland is runclioning normally. Mea­
suring urine calcium can hclp determinc whether the kidneys
are excreting the proper amount of calcium. and testing for
vitamin D, phosphorus. and/or magnesium can help deler-
2\
mine whether other deficiencies or excesses exiM. Frequently
the balance among thcsc different substances. and the
changes in them. arc just as important as the concemratiolls.
Calcium can be used as a diagnostic test jf the patient pres­
ents wilh symptoms thai suggest:
Kidney stones
• Bone disease
eurologic disorders
The lotal calcium lesl is Ihe leS( mo;! rrequenlly ordered
to cvaluatc calcium status. I n most cases. it is a good rencc­
tion of the amount of free calcium involved in Il1cLabolism
since the balance between free and bound is usually �lable
and predictable. However. in !'tome patients. the balance
between bound and free cnlciull1 is disturbed and total
calcium is not a good reflection of calcium status. In thoo,e
circumstances. measurement of ioniL.cd calcium i!\ neces­
sary. Some conditions where ionized calciull1 should be the
test of choice include: critically i l l patients who are receiv­
ing transfusions or I V fluids. patients undergoing major
surgery, and paticnts with blood protein abnormalities like
low albumin. Large fluctuations in ionized calcium can
cau!\c the hean to slow down or to beat too rapidly. can cause
muscles to go into spasm (tetany). and can causc confusion
or even coma. In critically i l l patients, it is extremely im por­
tant to know the ionized calcium levcl to be able to i ntervene
and prevent serious cOll1p l i cations. These include the fol­
lowing:
I . Kidney di scase. becausc low calcium is especially
common i n those wilh kidney failure:
2. Symptoms of too much calcium. such a!\ fatigue.
weakness. loss of appetite. nausea. VOITIltlllg. con­
stipation. abdominal pain. urinary frequency. and
increased thirM:
3. Symptoms of low calcium. such as cramp� i n your
abdomen. muscle cramps. or tingling fi ngers: or
4. Olher diseases that have been associaled with abnor­
mal blood calcium. such as thyroid d isease. inteMinal
disease. cancer. or poor nutrition.
An ion ized calcium test b, ordered when the patient ha�
numbness around the mouth and i n the hands and feet and
muscle spasms in the same areas. These can be symptoms
of low levels of ionized calcium. However. when calcium
levels rail slowly. many people have no symploms at a l l . The
patient may need calcium moniLOring when they have cenain
kinds or cancer (particularly breast. lung. head and neck,
kidney. and multiple myeloma), have kidney disease, or
have had a kidney transplant. Monitoring may also be neces­
sary when the patient is being treated for abnormal calcium
levels to evaluate the effecti veness of treatment� such as
calcium or vitamin D supplements.
Calcium absorpLion. usc. and excretion are regulated and
Slabil iLed by a reedback loop involving PTH and vitamin D.
Conditions and diseases that di�rupt calcium regulation can
cause inappropriate acute or chronic elevmions or decreases
in calcium and lead to symptoms or hypercalcemia or hypo­
calcemia. In most cases. total calcium is measured because
the test is more easily performed than the ionized calcium
22 CHAPTER I Principles in Assessing M usculoskeletal Disorders
test and requires no special handling of the blood ample.
TOlal calcium is usually a good reflection of free calcium
since the free and bound forms are typically each about half
of the total. However. because about half the calcium in
blood is bound to protein . lOlal calcium lest results can be
affected by high or low levels of protein. In such cases. it is
morc useful to measure free calcium directly using an
ionized calcium test.
Normal Calcium
A normal lOla) or ionized calcium resulL together with
other normal lab results generally means that calcium
metabolism is normal and blood levels arc being appropri­
ately regulated.
IIigil To/al Calcillm-llypercalcemia
Two of the morc common causes of hypercalcemia are:
1. Hyperparathyroidism. an increase in parathyroid
gland function: This condition is usually caused by a
benign tumor of the parathyroid gland. This fonn of
hypercalcemia is usually mild and can be present for
many years before being noticed.
2. Cancer: Cancer can cause hypercalcemia when iL
spreads to the bones, which releases calcium into the
blood. or when a cancer produces a honnone similar
to PTH, resulting in increased calcium levels.
Some oLher causes of hypercalcemia include:
1 . Hyperthyroidism
2. Sarcoidosis
3. Tuberculosis
4. Prolonged immobilizaLion
5. Excess Vitamin D i ntake
6. Kidney LransplanL
Low Tolal Calciwll-Uypoca[cemia
The most common cause of low total calcium is:
I. Low blood proLein levels. especially a low level of
albumin. I n this condiLion. only the bound calcium is
low. Ionized calcium remains normal and calcium
metabolism is being regulaLed appropriaLely.
Some oLher causes of hypocalcemia include:
I . U nderacLive parathyroid gland (hypoparaLhyroid­
ism)
2. InheriLed resistance LO the effecLs of parathyroid
hormone
3. Extreme deficiency in dietary calcium
4. Decreased levels of viLamin D
5. Magnesium deficiency
6. Increased levels of phosphorus
7. Acute i nflammalion of the pancreas ( pancrealitis)
8. Renal failure
9. MalnUlriLion
10. Alcoholism
Serum Protein Electrophoresis
Protein and i m munofixation electrophoresis tests give
the examiner a rough eSlimate of how much of each
proLein is present. The value of protein electrophoresis
lies in the proportions of proLeins and in the pauerns Lhey
creaLe on the elecLrophoresis graph. The value of immuno­
fixation electrophoresis is in identifying the presence of
a panicular Lype of i m munoglobulin. For example. certain
conditions or diseases may be associated with decreases
or i ncreases in various serum proteins, as reflected as
follows:
Albumin
Decreased: with malnutrition and malabsorption.
pregnancy. kidney disease (especially nephroLic syn­
drome), liver disease, inflammatory conditions, and
proLein-losing syndromes
II/creased: with dehydration
• Alpha, globulin
Decreased: in congenital emphysema (CII-antitrypsin
deficiency, a rare genetic disease) or severe liver
disease
Increased: in acute or chronic inflammatory diseases
Alpha, globulin
Decreased: WiLh hyperthyroidism or severe liver
disease. hemolysis (RBC breakage)
• II/creased: with kidney disease ( nephrotic syndrome).
acute or chronic inflammatory disease
BeLa globulin
Decreased: with malnutrition. cirrhosis
Increased: with hypercholesterolemia, iron deficiency
anemia, some cases of multiple myeloma. or mono­
clonal gammopaLhies of undetermined significance
(MGUS)
Gamma globulin
Decreased: variety of genetic i m mune disorders. and
in secondary immune deficiency
• Increased: polyclonal-chronic inflammatory disease.
RA, SLE. cirrhosis. chronic liver disease. aCULe and
chronic infection, recent immunization.
• Increased: monoclonal-Waldenstrom macroglobu­
linemia. muhiple myeloma. MGUS
TOLal protein
Low total protein levels can suggest a liver disorder, a
kidney disorder. or a disorder i n which protein is nOL digesLed
or absorbed properly. Some laboraLories also report the cal­
culated raLio of albumin LO globulins ( NG raLio). Normally,
albumin slighLly exceeds globulins. giving a normal A/G
raLio of slighLly over I . Because disease SLates affect Lhe
relaLive changes i n albumin and globulins i n differenL ways.
this ratio may provide a clue to the physician as to the cause
of the change in proLein levels. A low NG raLio may renect
overproducLion of globulins. such as seen in muhiple
myeloma or autoimmune diseases, or underproduction of
albumin. such as occurs with cirrhosis, or selective loss of
albumin from the circulaLion, as occurs with nephroLic syn­
drome. A high NG raLio suggesLs underproducLion of immu­
noglobulins. as may be seen in some genetic deficiencies
and in some leukemias. More specific tests, such as albumin.
liver enzyme tests, and serum protein elecLrophoresis. must
be performed to make an accurate diagnosis.
 CHAPTER I Principles in Assessing M uscu.loskeletal Disorders
Sodium
Hyponatremia is rarely caused by decreased sodium intake
(deficient dietary intake or deficient sodium in intravenous
fluids). Most commonly. hyponatremia is caused by sodium
loss (Addison disease, diarrhea, excessive sweating, diuretic
administration, or kidney disease). In some cases. hypona­
tremia is caused by increased water (drinking too much
water, heart failure, cirrhosis, kidney diseases that cause
protein loss [ nephrotic syndrome]). In a large number of
diseases (particularly those involving the brain and the
lungs, many kinds of cancer, and with some drugs), the body
makes too much 3Illidiurclic hormone, causing the patient
to keep too much water in the body.
A high blood sodium level means the patient has hyper­
natremia, almost always caused by excessive loss of water
(dehydration) withollt enough water intake. Symptoms
include dry mucous membranes. lhirsl, agitation, restless­
ness, acti ng irrationally, and coma or convulsions if levels
rise extremely high. In rare cases, hypernatremia may be
caused by increased salt intake without enough water,
Cushing syndrome, or insufficient antidiuretic hormone
(diabetes insipidus).
Sodium urine concentrations must be evaluated in asso­
ciation with blood levels. Concentrations may mirror blood
levels or be the opposite. The body normally excretes excess
sodium; thus the concentration in the urine may be elevated
because it is elevated i n the blood . .It may also be elevated
in the urine when the body is losing excessive sodium. In
this case. the blood level would be normal to low. I f blood
sodium levels are low as a resull of i nsufficient intake. then
urine concentrations will also be low.
Uric Acid
Higher-than-normal uric acid levels mean that the body is
not handling the breakdown of purines well. .Increased con­
centrations of uric acid can cause crystals to form in the
joints. which leads to the joint inHammation and pain char­
acteristics of gout. Uric acid can also form crystals or kidney
stones lhat can damage the kidneys.
Low levels of uric acid in the blood are seen much less
commonl y than high levels and are seldom considered
cause for concern. Although low values can be associated
with some kinds of liver or kidney diseases, exposure to
toxic compounds, and rarely as the result of an i nherited
metabolic defect, these conditions are typically identified by
other tests and symptoms and not by an isolated low uric
acid result.
Urinalysis
pH
Acid ity of urine is measllred by the pH.
.S'pecijil: Grat'ily
Specific gravity (SO) measures how dilute the urine is.
Water has a SG of 1.000 . Most urine is approximately1.0 10,
but it can vary greatly depending on when the patient drank
Iluids last or if the patient is dehydrated.
23
GII/cose
Normally, urine contains no glucose. A poslLJve glucose
occurs in diabetes. The number of people who have glucose
in their urine with normal blood glucose levels is small;
however, any glucose in the urine would raise the possibility
of diabetes or glucose intolerance.
Proteiu
Normally no protein is detectable on a urinalysis strip.
Protein can indicate ki dn ey damage, blood in the urine, or
an i n fection. Up to 10% of children can have protein in their
urine. Certain diseases require the use of a special. more
sensitive (and more expensive) test for protei n called a
microalbumin test. A microalbum i n test is useful in screen­
ing for early damage to the kidneys from di abetes, for
instance.
Illood
NormaJl y, urine comains no blood. Blood can indicate an
i n fection, kidney stones, trauma. or bleeding from a bladder
or kidney tumor and may be hemolyzed (dissolved blood)
or nonhemolyzed (intacl RBCs). R are ly, musc le inju ry can
cause myoglobin to appear in the urine, which also causes
the reagent pad to indicate blood falsely.
Bilirubin
Normally, urine cOlllains no bilirubin or u rob i l inogen. These
substances are pigments that arc cleared by the l iver. I n livcr
or ga ll bladder disease, they may appear in the urine as
well.
Nitrate
Normally negative. nitrate i n the urine usually indicates a
urinary tract infection.
Leukocyte Esterase
Leukocyte esterase is normally negative. Leukocytes are the
WBCs (or pus cells). WBCs in the urine suggest a urinary
tract infection.
Sediment
I tems such as mucous cells and squamous cells arc com­
monly seen. Abnormal findings would include >15 RBCsl
hpf (hematuria)-additional i nvestigation must be donc to
determi n e the source of the hematuria (renal or postrenal);
or >10 WBCs/hpf (pyuria)-additional investigation must
be done to determine the source of the pyuria (renal or
postrenal); or the presence of crystals, casts, renal tubular
cells. or bacteria (bacteria can be presen t if contamination
was present at the time of collection).
White Blood Cell Count
An elevated number of white blood cells ( WBCs) is called
leukocytosis, which can result rrom bacterial infections.
inflammation, leukemia, trauma, or stress.
A decreased WBC cou n t is called leukopenia. which
can result from many differen t situations, such as chemo-
24 CHAPTER I Principles i n Assessing Musculoskeletal Disorders

lhcrapy, radiation therapy. or diseases of the Immune fall below 1 0 mg/L, clinically active inflammation is no
system. longer present.
Blood and serum panels that are lIseful in the differential • RA latex
diagno1'>is include:
Bone panel Liver Function Tests
Alkaline phosphatase Alkaline phosphatase
Calcium B i lirubin-total and direct
Complete blood eOllnt (CBC) Cholesterol
Table 1 -5 explains whm increases or decreases in ench of Gamma-giutamyl transpeptidase (GGT) or peptidase
the components of the esc may mean. Elevated GGT levels indicate that something is going on
wiLh the liver but nOI specifically what. In general, the higher
the level is, the greater the inslI!1 will be to " liver. Elevated
SPEClTIC PROFILES
levels Illay be caused by liver disease. but they may aho be
Arthritis Panel caused by congestive heart failure. alcohol consumption.
ANA screen and use of many prescription and nonprescription drugs.
C-reactive protein (CRP) including nonsteroidal antiinflammatory drugs. lipid­
A high or increasing amount ofCRP in the blood suggests lowering drugs. antibiotics. histamine blockers ( used to treat
an acute infection or inflammation. In a healthy person, CRP excess slOmach acid production), antifungal agents. seizure
is usually less than 10 mg/L. Most infections and inflamma­ control medications. antidepressants. and hormones slich as
tions re>lilt in CRP levels above 1 00 mg/L. l f the CRP level testosterone. Oral contraceptives (birth control pills) and
drops. it means inflammation is being reduced. When results clofibrate can decrease GGT levels.

TAB l E 1-5

SUMMARY OF CBC COMPONENTS AND INTERP RETATIONS

Test Name IncreascdU1>ecrcased

WBC White blood cell May be increased with i nfections, inflammation, cancer. leukemia;
decre;'lscd with some medications (such as methotrexate). some
autoimmune conditions, some severe infections. bone marrow fuilurc.
and congenital marrow aplasia ( marrow docsn't develop normally)
% Neutrophil NeutrophillBandfSeg This is a dynamic population that varies somewhat rrom day to day
% Lymph!'> Lymphocyte depending on what is going on in the body. Significant increase!'> in
% Mono Monocyte panicu lar types are a.s�ociated with di frerent temporary/acute amVor
% Eo!'> Eosinophi l chronic conditions. An example or this is lhe increased number or
o/r- Ba�o Basophil lymphocytes seen with lymphocytic leukemia. For more informalion,
Neul rophil Neu troph illBandfSeg see Blood S mear and WBC.
Lymphs Ly mphocyte
Mono Monocyte
Eos Eosinophi l
Ba'io Basophil
RBC Red blood cell Decreased wil.h anemia: incrcased whcn too many made and with fluid
loss due 10 di arrhea, dehydration. burns
Hgh Hcmoglobin Mirrors RBe resu l�
Het Hematocri t Mirrors RBe results
MeV Mean corpu scular volumc Increased with BI: and Folate deficiency: dec reased wilh iron deficiency
and thalassemia
MCH Mean corpuscular hemoglobin Mirrors MCV results
MCHC Mean corpu !'>cular hemoglobin concentration May be del'reased when MCV is decrca!'>cd; increases limited to amount
of Hgb that will fil in.�ide a RBe
RDW Red blood cell distribution width Increased ROW i ndicutc:-. mixed popu lati on of RBCs: immature RBClt
tend to be larger
Platelet Platelet Decreased or increa�ed with conditions lhat affect platelet production:
decreased when greater numbers used. a.s with bleeding: decreased with
some inherited disorders (such as Wiskott-Aldrich. Bernnrd·Soulicr),
with Systemic lupus erythcmatoslI:', pernicious anemia, hypersplenism
(splcen takcs 100 many Olll of circuhuion), leukcmia. and chemotherapy
MPV Mean platelet volu me Vary with platclet production; younger platelets are larger than older ones
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 25__

LDH (See previous discussion.) such a s temporal arteritis. polymyalgia rheumatica, and
Serum glutamate pyruvate transaminase (SGPT) (See rheumatoid arthritis� it call also be used as a crude measure
previolls discussion.) of response in Hodgkin disease.
Serum glutamate oxaloacetate transaminase (SGOT) The use of ESR as a screening test in asymptomatic
Total protein-albumin and globulin persons is limited by its low sensitivity and specificity. When
a moderate suspicion of disease exists, the ESR may have
Parathyroid Function and Calcium Metabolism some value as a sickness index.
Alkaline phosphatase An elevaled ESR in Ihe absence of other findings should
Serum calcium n01 trigger an extensive laboratory or radiographic evalua­
Serum phosphorm. tion.
Total protein Uric acid
Urine calcium •
Synovial fluid analysis, including culture
Pancreas function lests Synovial fluid analysis is inexpen:-.ive and may be diag­
Amylase nostic in patients with bacterial infections or crystal-induced
CBC synovitis. According to lhe American College of Rheuma­
Glucose tolerance lology (ACR) clinical guidelines committee, Ihis analysis
Lipase should be performed in dle febrile patienl with an acule flare
of established arthritis to rule oul superimposed seplic arthri­
Joint Pain or Swelling Tests tis. In other situations. its main value is to permit classifica­
ANA screen tion into an inflammatory or noninflammatory category.
CBC Thus, synovial fluid analysis should be performed if il is
Heavy metal screen readily obtainable and the diagnosis is uncertain after history
RA latex interview. physical examinatioll, und standard laboratory
Scdimclllalion rate tests (Table 1 -6).
Although it is frequently ordered. the erythrocyte sedi­ The WBC count, differential counL. cultures, Gram slain,
mentation rate (ESR) is not a useful screening (eM; it is and polarized light microscopy are the mosl valuable sludies,
useful only for diagnosing three diseases: ( I ) myeloma, ( 2 ) Noninflammatory fluids generally have fewer than 2000
"
temporal arteritis, and ( 3 ) polymyalgia rheumatica (in which WBCs/ml11 with fewer Ihan 75% polymorphonuclear leu­
it may exceed 100 nlln/hour). kocytes. The ACR commiltee suggests Ihal unexplained
ESR is commonly lIsed for a di fferential diagnosis for innammutory fluid, panicularly in a febrile patient, is
Kawasaki disease. and it Illay be increased in some chronic assumed to be inrected until proven otherwise by appropri­
infective conditions such as tuberculosis and infective endo­ ate culture.
carditis. The ESR is a componenl of the Pediatric Crohn Normal joints contain a small amount of synovial fluid
Disease AClivily Index (PDCAI), an index for assessmenl of with the following characteristics:
severity of innaml11atory bowel disease in children. Highly viscous
The clinical usefulness of ESR is limited to monitoring Clear
the response to therapy in certain inflammatory diseases Essentially acellular

TAB I F 1-6
CATEGORJ[S OF SYNOVIAL F LU I D BASED UPON CLIN ICAL AN D LABORATORY F I N D I NGS

Measure Normal Noninflammatory Inflammatory Septic Hemorrhagic

Volume, IllL (knee) <3.5 Often >3.5 Oflen >3.5 Often >3.5 Usually >3.5
Clurity Tnmsparenl Transparent Translucent-opaque Opaque Bloody
Color Clear Yellow Yellow to opalescent Yellow to green Red
Viscosity H igh High Low Variable Variable
Wac. per mlll3 <200 200-2.000 2000- 1 0.000 >100.000* 200-2.000
PMN<;. percent <25 <25 ;,50 ,,75 50-75
Culture Negative Negative Negative Often positive Negative
Total protcin. gldl 1-2 1-3 3-5 3-5 4-6
LDH (comp<lrcd to Vcry low Very low High Variable Similar
level!. In blood)
Glucose. mgldl Nearly equal Nearly equal to blood >25. lower than blood <25. much lower Nearly equal 10 blood
10 blood than blood

LDH, Laclic dehydrogenase: PMN, polymorphonuclear ce tl: WOc, white blood cell.
·Lower with infcctiol1\ caused by partially treated or low virulence organi!'!tns
26 CHAPTER I Principles in Assessing Musculoskeletal Disorders

•
Protein conccnLration approximately one-third thaL of TAB L E 1 -7
plasma
SUMMARY OF THYRO I D-STIMUlATING HORMONE
Glucose concentration similar to that in plasma
TEST RESULTS AND INTERPRETATIONS
If a synovial effu�ion is present and anhrocentesi� is
indicated, joint nuid should be routinely analyzed for TSH T4 T3 Interpretation
volume, clarity, color, viscosity, crystals cell counL differ­
High Normal NOnllal Mild (subclinical)
ential. Gram stain. and culture. In certain circumstances. the
hypothyroidism
presence and type of crystals should also be assessed. Syno­ High Hypothyroidi"m
Low Low or normal
vial fluid is subsequently categorized as either normal. non­ Low Nonnal Normal Mild ( ..ubclinical)
inflammatory. inflammatory, septic, or hemorrhagic based hypcnhyroidi!im
on the clinical and labonuory analysis. The differential diag­ Low High or normal High or Hyperthyroidism
nosis of each of these specific calegories is broad and nOI normal
necessarily exclusive: Low Low or normal Low or normal Rare pilUitury
NOllinjfallllJl(l[ory effusions may be caused by degenera­ (secondary)
hypothyroidism
tive joint disease (osteoarthritis). trauma. osteochondritis
dissecans. neuropathic arthropathy, subsiding or early
n. Triiodothyronine: T-I. thyroxinc� TSN. lhyroiu-\timul;lling hurmone.
innammation, hypertrophic oSleoarthropathy. and pig­
mented villonodular synovitis.
Illfiall/II/atory effusions may be caused by RA, acule hormone medication in patients who are being treated for an
crystal-induced synovitis. reactive arthritis (formerly underactive (or removed) thyroid gland. In rare cases. a low
Reiler syndrome), ankylosing spondylilis, psoriatic TSH resuh may indicale damage 10 the piluilary gland that
arlhriti�. arthritis associated wilh inflammatory bowel prevents it from producing adequate amounts of TSH.
disease, rheumatic fever, SLE. hyperuophic osteoar­ Whelher high or low, an abnormal TSI I indicates an
thropathy, and scleroderma. Rheumalic fever, SLE, and excess or deficiency in the amount of thyroid hormone avail·
scleroderma can also cause a noninflammatory effusion. able 10 the body, bUI il does nOI indicate Ihe reason why. An
Septic effusions may be caused by bacleria. mycobacte­ abnormal TSH lest result is usually followed by additional
ria, or fungus. testing to investigate the cause of the increase or decrease.
Hemorrhagic effusions may be caused by hemophilia or Table 1 -7 summarizes test results and their potelllial
other hemorrhagic dimhesis, scurvy, trauma with or meaning.
withoul fraclure, neuropalhic arthropathy, pigmenled vil­
lonodular synovitis. synovioma, hemangioma. and other Thyroxille
benign neoplnsms. In general. high free or tOlal T4 results may indicale an
overaclive thyroid gland (hyperthyroidism). and low free or
Thyroid Profile 10lal T4 resulls may indicale an underactive thyroid gland
Free Thyroxine Jilt/ex (hypothyroidism). The test resuils alone are nOI diagnoslic
The free thyroxine index ( Ff l or T7) is a mathematical but will prompt t.he examiner to perform additional teMing
computation thm allows lhe laboratory to estimate the free 10 invesligale the cause of Ihe excess or deficiency. Both
Ihyroxine index from Ihe Ihyroxine (T4) and lriiodOlhyro­ decreased and increased T4 results are associated with a
nine (T3) uplake leSls. The resuhs lell how much thyroid variety of temporary and chronic thyroid conditions. Low
hormone is free in the blood stream 10 work on the body. T4 resuils in conjunction wilh a low TSH level. or high T4
Unlike Ihe T4 alone, Ffl is not affected by estrogen resuils along wilh a high TSH, may indicate a piluitary gland
levels. condition.
Table 1 ·8 summarizes lest results and their potential
Thyroid·Stimulating Hormoll(' meaning.
A high Ihyroid-stimulaling hormone (TSH) resuh often
means an underactive thyroid gland that is not responding T,.iiodot"yrollille
adequalely 10 the slimulalion of TSH because of some IYpe Increased or decreased thyroid hormone results indicate an
of acute or chronic thyroid dysfunction. In rare instances, a imbalance bel ween Ihe body's requiremenls and supply, bUI
high TSH resuh can indicate a problem wilh Ihe pituilary they do not lell the examiner specifically whal i s cau,ing Ihe
gland. such as a tumor that produces unregulated levels excess or deficiency.
of TSH, in what is known as secondary hyperThyroidism. Table 1 -9 summarizes test results and their potential
A high TSH value can also occur when palienls wilh a meaning.
known thyroid disorder (or those who have had their thyroid If a patient is being treated with antithyroid medication
gland removed) are receiving inadequate thyroid hormone for hyperthyroidism and Ihe T3 (or, morc frequeJ1lly, the T4
medicatioll. or TSH) is normal, then the medication is likely controlling
A low TSti resull can indicate an overactive thyroid the condition. If the T3 (or T4) is elevaled, Ihen Ihe medica­
gland (hyperthyroidism) or excessive amOUI1lS of dlyroid lion is not sufficient to control the condition, and the palient
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 27

TAB L E 1·8 the most useful in this range. When patients in Ihe gray lone
have decrea\ed levels of free "SA. lhey have a higher prob­
SUMMARY OF THYROX I N E (T4) TFST RESULTS
ability of proslate cancer; when Ihey have elevated levels o f
AND I NTERPRETATIONS
free PSA. the risk is dimin ished. The ratio of free to total
T4 T8H T3 Interpretation PSA can help the examiner decide whelher a proslate biopsy
should be performed.
Nannal HIgh NOnllal Mild (�ubcJinic<ll)
When the complexed PSA (cPSA) test is used as a screen­
hypoLhyroidi..m
ing tool. increa.\cd leyels may indicate an increased ri\k of
Low High Low or nonna1 Ilypothyroidi..m
Nannal Low Nonnni Mild huOclinicnl) prostate C�1J1cer. whereas lower Icvels indicate a decreu\cd
hyperthyroidism risk.
High or normal Low High or nomlal Hypcnhyroidi"m In addition to lhe inlroduction of the free PSA and cPSA
Low or normal Low Low or nonna! Rare pituitary tests. efforts have been made to increase the u"iefulnes!o. of
(!ooccondary ) the total PSA as a screening 100\. A l lhough none of these
hypothyroidi..m efforts have been widely accepted yet. researchers are study­
ing them. and some examiners are using them. These factors
n. Triiuollihyronlllc; 14. thyroxine; TW/, thyroill-..llIl1ulallllg hormone.
include:
PSA velocilY. This tesl mea,ures the change In PSA con­
centrations over time. If the PSA continues 10 risc sig­
nificantly over time. such as 3 or more years. then proslatc
TABLE I ·')
canccr is morc l i kely present. I f it climbs rapidly. then lhe
SUMMARY Of TRIIODOTHYRO N I N E (D) TEST patient may have a morc aggre...sive form of cancer.
RESULTS AND INTERPRETATIONS •
PSA doubling lime. This leM i!o. another version of the
T3 T4 T8H Interpretation PSA velocity. 11 measures how rapidly Ihe PSA concen­
tration doubles.
Nonnal Nannal High Mild bubclimcal)
PSA densilY. This te'l is a comparison o f Ihe PSA con·
hypothyroidi..m
centration and the volume o f the prostate (as metlsurcd
LO\I, or nc.mnal Lo" High Hypothyroidism
r\onnal Nonnal Low Mild (..ubclinical)
by ultrasound). Paliel11S with larger prostates tend to

hyperthymidi..m produce morc PSA; thus. thi'i factor is an adjuslment to

High or nonnal High or 00011al Low Hypcnhyroidh,m compensate for the SilC.
Low or normal Low or 110mlal Lo" Rare pituita!) Age-specific PSA ranges. Given Ihat PSA le,e1s nalurally
hccondaryl increase as a man ages. experts have proposed thal nonnal
hypolhyroidi'im ranges be tai lored to a man's age.
During trealment for prostale cancer. the PSA level
7J, Triiodulh)roninc; T.J, Ihyro'(illl:: TSH. Ih)roji.J-_�lillluJaling hormone.
should begin to fall. At the end of treatment. it should be al
very low or undetectable levels i n the blood. I f concentra­
tions do not fall to very low levels. Ihen lhe trcalment ha,
may be experiencing symptoms associated with hyperthy­ not been fully effective. After Ireatment. Ihe PSA lesl is
roidi!o.ITI. perfonned at regular intervals to monitor the patient for
recurrence. Because even tiny increases can be signi ficant.
Prostate Profile patients may want to have their monitoring PSA tests per­
I'ro.\llIl(·.Sp(·ciji(' \ IIli/.:(·11 fonned by the same laboralory each time so Ihal testing
The normal value for lOWI proslale·specific anligen (PSA) \'arialion is kept to a minimum.
has heen ScI at less Ihan 4.0 ng/mL blood. Some experls
believe lhat Ihis level should be lowered to 2.5 ng/mL to IJro.\ltItil- \cill Phmpllllla.\"l!
detect more C3SC!o. of pro"tate cancer. Other" argue that this Pro'tatic acid phosphatase (PAP) is an enlyme produced by
change would exacerbate overdiagnosing and overtreating the prostate. It may be found in increased amount.s in mcn
cancers that are not clinically signilicant. who have prostate cancer or other diseases. This same
Mosl experls agree thai palients with a total PSA level enzyme is also found in significant amounts in female
grealer than 10.0 ng/mL are aI an increased risk for pros laiC ejaculate.
cancer (more than a 67CJr chance. according to the American The highesl levels of PAP are found in melaslasized pros·
Cancer SocielY). Levels belween 4.0 and 1 0.0 ng/mL may tate cancer. Diseases of the bone (e.g .. Pagel di,ease. hyper­
indicate pro'itatc cnncer (approx imntcly a 25% chance. parathyroidism). diseases of blood cells (e.g .• sickle-cell
according to the Americnn Cancer Society). benign prm,tntc disease. multiple myeloma). or lysosomal storage disease,
hyperplasia. or pro'itutitis. Thc'ie conditions are more (e.g .. Gaucher disease) will sho\\ moderalely increased
common in older adult males. as is a general increase in levels.
PSA levels. Concentrations of total PSA between 4.0 and Certain medicmioJ1!o. can cau-,e temporary increa!o.c!o. or
10.0 ng/mL arc often called the gra\" :olle. The free PSA is decreases ill PA P levels. Manipulation of the prostate gland
28 CHAPTER I Principles in Assessing M usculoskeletal D isorders

through massage. biopsy. or rectal examination before a tcst lligll-Dellsity Lipoproteill Cilolesterill
can increase the level. LDL cholesterol
• Triglycerides
Hypertension ( Coronary Risk Profile)
Cholesterol Health Screen
• Coronary risk indicator • Albumin
This is a group of tests and health faclOrs have been Low albumin levels can suggest liver di\ease. Other liver
proven to indicate a patient's chance of having a coronary enlYme tests are ordered to detemline exactly which type of
evenl. They havc been refined to indicate the degree of risk: liver disease. Low albumin levels can also reflect diseases
slight, moderate, or high. in which the kidneys cannot prevent albumin from leaking
Perhap� the most important indicators for cardiac risk are from the blood into the urine and being losl. In this case. the
those of the personal health history. Age, hereditary factors. amount of albumin (or protein) in the urine also may be
weight. smoking. blood pre sure, exercise h istory, and dia­ measured. Low albumin levels can ;]Iso be seen in inflam­
betes arc all important in determining risk. The lipid profile mation. shock. and malnutri tion. Low albumin levels may
is the most important blood test for risk assessmenl. Other also suggest conditions in which the body does nOl properly
tests, bOlh invasive and noninvasive, may be used in cardiac ab,orb and digest protein (e.g .• Crohn di,ea,e. 'prue) or in
risk assessment. Noninvasive tests may include an electro­ which large volumes of protein are 10M from the intes­
cardiographic stress lest, thallium SlrcSS lest. electrocardio­ tines.
gram, computed tomographic scan. and echocardiogram. High albumin levels usually reflect dehydration.
I nva�ivc tests include an arteriogram and cardiac catheter­ NG ratio (See previous discussion.)
ization. Alkaline phosphatase
The lipid profile measures cholesterol. triglycerides. HDL Anion gap
(good cholesterol), and LDL (bad cholesterol). Triglycerides Anion gap can be classified as high. normal. or. in
are the major form of fat found in the body. and their func­ rare cases, low. A high anion gap indicates a lo�s of bicar­
tion is to provide energy for the cells. The de,irable ranges bonate without a subsequent increase in chloride. Electro­
for the components of the lipid profile include the follow­ neutrality is mail1lained by the increased production of
ing: anions such as ketones, lactate. phosphate. and sulfate; lhese
Cholesterol <200 mg/dL (5. 1 8 mmollL) anions are not part of the anion-gap calculation. and there­
HDL cholesterol >40 mg/dL ( 1 .04 mmollL) fore a high anion gnp results. In patiel1l� with a normal
LDL cholesterol < 1 00 mg/dL* (2.59 mmol/L) anion gap. the drop in bicarbonate is compensated for by
Triglycerides < 1 50 mg/dL ( 1 .70 mmollL) an increase in chloride and hence i ... also known til., hyper­
If any or all of the results arc significantly outside these chlorcmic acidosis.
ranges, the risk of a cardiac event is increased. If they are
only slightly outside the desirable level. diet, exercise, med­
ication. or any combination of these treatments may be suf­ Higtt Illiol/ Gap
ficient to reduce the abnormal levels. thereby reducing The bicarbonate 10M is replaced by an lInmea�ured anion.
ri�k. and thus a high anion gap will be present in the following
Another test gaining importance is serum homocysteine. disorders:
Homocysteine is un amino acid that comes from the normal Lactic acido�is
breakdown of proteins in the body and appears to be a beller Ketoacidosis
test than cholesterol testing for predicting heart disease, Diabetic ketoacidosis
stroke. and reduced blood now to the hands and feel. Lipo­ Alcohol abuse
protein A (Lpl a J ) is a lipoprotein consisting of an LDL Toxins:
molecule with another protein (apolipoprotein A) attached Ethanol
to il. Lp(a) is similar to LDL but does not respond to typical Ethylene glycol
strategies to lower LDL such as dict. exercise, or most lipid­ Lactic acid
lowering drugs. Given that the level of Lp(a) appears to be Methanol
genetically determined and not easily altered. the presence Paraldehyde
of a high level of Lp(a) may be used to identify individuals Aspirin
who might benefit from more aggressive treatment of other Cyanide. coupled with elevated venous oxygenation
risk factors. A fairly new test, high-sensitivity (hsCRP), may Iron
be measured on apparently healthy patients to detemline if Isoniazid
they are at risk for a coronary event. evcn if their lipid levels The mnemonic MUDPILES is used to remember the
are normal or borderline elevated. causes of a high anion gap.
Methanol/metformin
*Oplim:tl le'o'cl, will depend on the number and type of ri-;k facloN prcsclll Uremia
and whether testing i.. being used in primary or secondary intervention I!iabetic ketoacidosis
 CHAPTER I Principles i n Assessing Musculoskeletal Disorders 29

faraldehyde/propylene g l yco l Blood, which consists largely of the protein hemoglobin,

In reClion/ischcl11i vi
.. son i azid is broken down by digestive enzymes of the upper GI
Lactate tract into amino acids.
Ethylene glycol/ethanol The amino acids. which origimlte from the hemoglobin,
S.al icylate,/starvation are reabsorbed by the lower G I tracl.
Some people. especi al ly those not in the emergency Urea is a break-down product of amino acid catabolism;
room. find the mnemonic KILU easier to remember and also therefore, the protein meal from an upper GI bleed shows
more useful cli ni cal ly : lip in the blood as urea.
Ketone; Because of decreased muscle mass. elderly patients may
Ingestion have an e le vated B U N/creatinine ratio at baseline.
,Lactic acid Calcium
Uremia Calculated LDL
All of lhe componeJ1ls of M UDPILES are also covered CBC
with the KILU device. with the added imperative that these Chloride
th ings can kill a patie nt . Cholesterol
Ketones: morc slraigillfofward than remembering dia­ CholeslCrol-HDL ratio
betic ketosis, starvation ketosis, and so forth. Creatinine
Ingeslion: methanol. metfonnin. paraldehyde, propylene GGT (Sec earlier discussion.)
glycol. i;oniazid. ethylene glycol. ethanol. and sal icy­ G lobul i n
lales are covered by i ngestion. These substances can Globulins are roughly divided into alpha. beta. and
be considered as a single group-illgesliolls-during gamma globulins. These values can be separtlled and mea­
the initial con�idcration. especially when nOt triaging sured in the laboratory by techniques called electrophoresis
a patient in the emergency room. and densitometry. The gamma fraction includes the variou�
LaclicAcid: including that caused by infection and shock types of alllibodies ( immunoglobulins M, G, and A).
(U,ually the bicarbonate lost is replaced by a chloride Normal values are:
anion. and thus the anion gap is normaL) Serum globulin: 2.0 to 3.5 g/dL
Gastrointestinal loss of bicarbonate (e.g., diarrhea) IgM component: 75 10 300 mgldL
( ote: Vomiting causes hypochloremic alkalosis.) IgG component: 650 to 1 850 mgldL
Renal loss of bicarbonate (e.g.. proximal renal tubular IgA component: 90 to 350 mgldL
acidosis) I ncreased gamma globu l i n proteins may i ndicate:
Uremia: Renal dysfunction (e.g .. renal failure. hypoal­ Multiple myeloma
doslcronism, distal renal tubular acidosis) Chronic inflammatory disease (e.g., RA, SLE)
A low anion gap i� re l at ive ly rare but may occur from the Hyperimmun ization
presence of abnormal positively charged proteins. as in mul­ Acute infection
tipl e myelom a or in the settin g of a low serum albumin
, Waldenstrom macroglobulinemia
level. Glucose
Bilirubin (IOtal) HDL
BUN (See earlier discussion.) • Ionized calcium
BUN-creatinine ratio LDH
The B UN/creatinine ratio is a rmio of two laboratory test Phosphorus
values: the BUN and serum creatinine. It is used in the Potas� i U 111
United States. Elsewhere (Canada. Europe). urea is used • Serum glutamate ox aloaccta te transaminase
instead of BUN; thus. it is the urea-lo-creatinine ratio, also Serum glutamate pyruvate transaminase
urea-creatinine ratio. and urea/creatinine ratio. Sod i um
The BUN/creatinine ratio is predictive of prerenal failure, T4 radioimmunoassay ( R I A )
if the BUN-to-creatinine r'Jtio is greater than 20 or the T4 b y RIA i s the most widely used thyroid test of a l l . I t
urea-Io-creatinine ratio of marc than 0. 1 0 and urea of more i s frequently called a T7, which means that a resin T3 uptake
than 1 0. I n prerenal fai lure, urea rises out of proportion (RT3u) has been accomplished 10 correc t for certain medica­
to the creatinine because of enhanced proximal tubular tions such as birth control pills, other hormones. seizure
reabsorption . medication. cardiac dru gs, or even aspirin that may alter the
The BUN/creatinine ratio is useful for the diagnosis of routine T4 tesl. The T4 renects the amount of T4 in
upper gastrointestinal ( G I ) bleeding in patients who do not the blood. If the patient does not take any type of thyroid
exhibit overt vomiting of blood. In children. a B U N/cremi­ medication. this test is u su al ly a good measure of thyroid
nine ratio of 30 or above has a sens i tivity of 68.80/0 for upper functi on .

GI b leeding and a specificity of 98%. • Total carbon dioxide

The reason the urea concentration increases in upper GI Carbon dioxide levels that arc higher or lower than
bleeds is as follows: nonnal suggest that the body is having troublc mainwining
30 CHAPTER I Principles in AssessLng Musculoskeletal Disorders

Normal synovial nuid is a hypocellular. avascular con­

nective tissue. In disease, the synovial Huid increases i n

SYNOVIAL FLUID volume and can b e aspirated. Synovial Auld is a transudate

For three significant aspects, analysis of synovial
fluid differs from other body fluids:
I . Neoplastic processes rarely arfect synovial joints.
2. Recognition of noncellular paniculate material, such
as microorganisms and crystals and cartilage frag­
ments. is essential for defining the disease process
affecting the joint.
3. Diagnostic information comes not only from recogni­
tion of cell types but also from their quantification.
its acid-base balance or that the electrolyte balance is upset,
perhaps by losing or retaining fluid. Both of these imbal­
ances may be the result of a wide range of dysfunctions.
Total protein
Triglycerides
Uric acid
• Synovial fluid
of plasma supplemented with high molecular weight. sac­
charide-rich 1110lecules. The 1110st notable of these is
hyal uronan (hyaluronic acid). which is produced by fibro­
blast-derived type B synoviocyte ( Box 1-3). Variation in the
volume and composition of synoviai lluid reRects pathologic
processes within the joint.
ORTHOPEDIC TESTS
In the orthopedic physical examination, a test is positive or
a sign is present when the procedure dupl icates the patient's
complaint or symptom. Tests are based on joint, muscle, or
nerve function. If testing causes different pain or symptoms,
it may indeed be significant, but the result is nOI positive for
the findings that Ihe test was designed to elicit.
During an examination, the examiner must use techniques
that defeat the human tendency of exaggeration. The exam­
iner must conduct several tests and multiples of similar tests
so that the patient is not aware of which specific tissue func­
tion is being examined. Wilh lime and exposure to a myriad
of orthopedic disorders. examiners develop the skill and

IIOX 1-3 accuracy necessary to reach diagnoses efficiently. However.

interpreting the results of examination processes in a clini­
N O RMAL SYNOVIAL F L U I D
caJly meaningful way requires the examiner to consider the

OsmOlarity 296 mO,mIL reliability of the clinical measurements and tests.

pH 7.44 Interpretation and analysis of examination procedures
Carbon dioxide pressure 6.0 kPa (range 4.7-7.3) depend not only on Ule reliability and validity of such mea­
Oxygen prc�surt! <4.0 kPa sures, bUI also on the sensitivity and specificity of the signs
Potassium 4.0 mmoJIL elicited by the test procedures.
Sodium 136 mmoUL
Calcium 1 .8 mmollL
Urea 2.5 mmoUL DIAGNOSTIC IMAGING MODALITIES
Uric acid 0.23 mmollL IN ORTHOPEDICS
Glucose tOO mmollL
I maging procedures are important to the diagnosis and man­
Chondroitin sulfate 40 "'gIL
Hyaluronate 2. t 4 gIL agement of an orthopedic condition. The decision to use any
Cholesterol Small amounts diagnostic imaging procedure, especially ionizing imaging
TOl..lI prolein -25 gIL procedures, should be based on a demonstrated need and
Albumin -8 gIL should be used only after an adequate medical history is
(Xt-antitrypsin 0.78 mcglL obtained and a physical examination is conducted. The deci­
CcnllopJasmin -43 I1lgIL sion to use any imaging procedure must also be based on
Haptoglobin -90 mgIL
the assumption lhat the results of the eXIDllination. even if
(X.:z-macroglobin 0.31 gIL
negative, will significantly affect the treatment of the patient.
Laclofcrrill 0.44 mglL
The value of the information gained from the imaging exam­
IgG 2.62 gIL
ination must be worth the possible detrimental effects of the
IgA 0.85 gIL
procedure. In imaging modalities tJlat use ionizing radiation
IgM 0. 1 4 gIL
lL-I� 20 pglmL (plain-film radiography, fluoroscopy, and CT), the possible
IL-2 1 5 . t U/mL effect of radiation on the patient or future offspring must be
TNF-ct 1 .38 hglmL considered (Fig. 1 - 1 7 ).
INF-ct 350 U/mL
INI'-o 13.7 U/mL Plain-Film Radiography (Conventional
Radiography)
IgA. Imml.lll/)gfo/JII/ifl A; IgG. imfllllllog/oi>u/ifl G; IgM. imlllllllog!obllUn
Plain-film radiography. or conventional radiography. pro­
M: IL. imerle"k;lI: INF. illft:ljI!l"Ofl: TNF. tulllor-necrosis/aclor:
Adapted from Klippel lH. Dieppe PA: RlwulI/lIw/agy. \'0/ /·2. ed 2. London. vides a wide and di verse array of diagnostic data about
1998. Mosby. musculoskeletal problems. such as soft-tissue injury. bony
 CHAPTER I Principles in Assessing Musculoskeletal Disorders
malalignment, loss of integrity of the osseous structures. and
joint space abnormality.
Plain-film X-ray examination is an efficient way to dis­
cover dislocations, fracLUres, the static component of ana­
tomic subluxations. certain types of stress injuries. metastatic
disease, some types of primary tumors, metabolic disease,
degenerative arthropathic diseases (Table 1 - 10). and abnor­
malities in the growth plate.
Soft-tissue structures require careful scrutiny on film
because they may offer subtle clues to serious or underlying
pathologic abnormalities.
A radiologic evaluation of the traumatized sites should
include films of the adjacent joints. If a need exists for
special projections, other radiologic investigation may be
necessary (Table I - I I ).
Care must be taken to investigate the possibility of asso­
ciated injuries in trauma victims (Table 1 - 1 2). Patients may
not realize that such injuries have occurred.
lA I\ L E 1 · 1 0
PLAtN- F t LM EVALUATION t N DEGENERATIVE
ARTH ROPATHIC DISORDERS
Diagnosis Site of Plain-Film findings
Psoriatic anhritis Hand. sacroiliac joints (common):
pubis symphysis, hip, knee (less
common)
Rheumatoid arthritis Wrist and hand, shoulder. knee.
cervical spine. hip
Spondyloarthropathy Sacroiliac joints. thoracolumbar spine
Osteoarthritis Lumbosacral spine, hip, knee. foot
and ankle, hand
f i G . 1 - 1 7 From left to right and top 10 bottom, An arias of
I/ormal roelllgell variants fhat may simulate disease (by
Theodore E. Keats). gonadal shielding, sandbag, DuPont
Quanta Delail Rare Earth X-ray casselle screens, and com­
patible film.
31
The patienl's history and clinical evaluation are guides
that help determine which portion or portions of the body
requires plain-film imaging and how many different views
should be produced (Fig. 1 - 1 8 ) .
Radiography i s a useful tool in the initial assessment
of rheumatologic disorders because it may providc specific
infomlalion thaI contributes to establishing a diagnosis.
Various rhcumatologic disorders have unique fealUres that
can be easily detcclCd with plain-film radiographs. Abnor­
malities on plain-film radiographs can be detected with a
high degree of sensitivity. Serial radiography is useful in
measuring structural damage, and features such as erosions.
joint space narrowing. and disease-specific findings can hclp
gauge response to therapy (Dry. 2003).
Tomography
Conventional tomography is also known as thill-section
radiography, planigraphy, and linear tomography. Conven­
tional tomography is largely replaced by CT. However, some
circumstances. such as evaluating sublle alteralions of bone
density and ruling out fracture, necessitate conventional
tomography. CT scans are used for more detailed apprecia­
tion of skeletal pathologic processes, which can help evalu­
ate suspected intervertebral disc protrusions or herniations,
facet disease. or central canal and lateral recess stenosis. I f
spinal disease is suspected and is not well idenlified o n plain
films and the patient is not responding to care, a CT scan is
indicated. A CT scan is especially useful for the appreciation
of bone and caJcifications and surpasses magnetic resonance
imaging ( M R I ) in this regard.
CT has been useful in a wide variely of musculoskeletal
disorders, including those related 10 trauma (Fig. 1 - 1 9), back
pain (e.g., herniated nucleus pulposus) (Fig. 1 -20), and met­
abolic bone disease (e.g .. osteoporosis, tumor and soft-tissue
masses).
Two thirds of patients with multiple injuries suffer from
blunt chest trauma. and severe thoracic trauma is associated
with multiple injuries in 70% lO 90% of cases (LoCicero J
3rd. MallO •. 1989; Pinilla. 1982).
F I G . 1-18 Displacemenl of fat pads in the elbow by joint
effusion. (From Klippel JH. Dieppe PA: RheumatOlogy. vol 1-2. ed 2.
London. 1 998. Mosby.)
32 C HAPTER I Principles in Assessing Musculoskeletal Disorders
O R1 1101'1 \l I L GAMli r I 2\
ARTHRITIDES: D IAGNOSIS AND CLINICAL PROGRESSION ASS.ESSMENT
STEPS IN RHEUMATOID ARTHRITIS, PSORIATlC ARTHRITlS, ANKYLOSIS
SPONDYLITlS, AND OSTEOARTHRITIS
Rheumatoid arthritis
Serial radiographs (posteroanterior [PAl view) of hands,
wrists, and feet at baseline and at 6-month intervals for
a minimum of 2 years after onset
Monitoring frequency decreased after 2 years in patients
without erosions at 2 years
• Distinguishing radiographic features: bilateral symmetri­
cal involvement of the small joints ( hands, wrists, and
feel),juxtaanicular osteopenia, lack of proliferative bone
response, marginal erosions. joint space narrowing.
Psoriatic arthritis
• Serial radiographs (PA view) of hands, wrists. and feet
(and spine and other joints if symptoms are present) at
baseline and at 6-month intervals for a minimum of 2
years after onsel
• Distinguishing radiographic features: asymmetric and
possibly oligoarticular joint involvement, initially mar­
ginal erosions lhat become irregular and ill defined, distal
interphalangeal joint involvement, abnormalities in pha­
langeal tufts and at sites of uuachmcnts of tendons and
ligaments to the bone, possible spondylitis, paramarginal
syndesmophytes in nonconsecutive vertebrae, sausage
digits, proliferative bone changes, and ankylosis
Ankylosing spondylitis
Serial radiographs (anteroposterior IAPI view) of pelvis.
sacroiliac joints. and axial spine
• If early ankylosing spondylitis is suspected, repeat pelvic
radiographs 6 months from baseline; otherwise, serial
Adapted from Ory PA: Radiography in the aSSCS\IllC'llt of mu,>culoskeletal condj(ion�, Ik�/ Prtlc/ R('\ Clin Rlll'lflll 17(�1:495·5 1 2 . 2003.
Among hlum injuril!!oi 10 the chest. lung contllsion is
con!'lidcred one of the mo�t important factors contrihuting to
the incre"lsed morbidity and mortality of patients with mlll�
riple injuries (Johnson. Cogbi ll. Winga, 1986: Schild el al.
1 986).
The usual diagnostic work-up in rhe emergency
department for blunt injuries to the chest includes a routine
chest x-ray taken in the supine position m
; d an ultrasound.
Despite this approach. significam injuries such as pneumo­
thoraces. hemothoraces. and lung contusions can be missed
during the initial trauma assessmem (W:'lgner, Jamieson,
(989).
CT scanning is accurate in visualizing intrathoracic inju­
ries. In addilion, the availabil i ty, reliability, and low com­
plication rate of CT scans has led to its widespread use in
the evaluation of blunt trauma.
Clinicians often use the noninvasive technique of quan­
litatjvc CT to mea�ure bone mineral density.
radiographs of pelvis, sacroiliac joints, and axial spine
annually or every other year
Serial radiographs ( l ateral and AP views) of cervical,
thoracic, and lumbar spine annually or every other year
Radiographs (PA view) of hands and feet at baseline;
fol low-up radiographs based on clinical features
Distinguishing radiographic features: cervical lesions not
typically associated with instability and subluxations of
the lower five vertebrae as in rheumatoid arthritis, less­
severe hip lesions than in rheumatoid arthritis without
protrusions, osteophytcs along the margin of articular
canilage of the femoral head, marginal syndesmophytes
in consecutive vertebrae. sacroiliilis. 'bamboo spine,'
smaller and more localized erosions, and less frequent
joint space narrowing and osteopenia compared with
rheumatoid arthritis
Osteoarthritis
• Radiographs (PA view) of the hrulds and fect annually
• Radiographs of the hips (AP pelvic in supine position)
and knees (standing, weight-bearing AP with full knee
extension) annually
Distinguishing radiographic features of osteoanhritis:
osteophytes, subchondral sclerosis
Distinguishing radiographic features of erosive osteoar­
thritis: distribution in distal joints of fingers similar to
that of psoriatic anhritis; centrally located erosions; ero­
sions typically absent i n metacarpophalrulgeal joints
Discography
Although effective, discography has been a controversial
imaging modality for spinal disc disease. Clinicians use
discography for specific cases of spinal pain that arc recal­
citrant to conventional therapy.
Discography is an important diagno�tic procedure in which
disc pressure comrolled by need le injection is correlated
with degree of lumbar pain rcp<Jrred by the patient. Although
imaging studic'i. such MRI. call be used to document paLho­
logic changes in the disc. some studies have 'ihown a poor
con'e1ation between MRI findings and clinical symptoms
because di!'lc degeneration and hernimion incrc<'lsc wil.h
normal aging (Boden el at. 1990).
The high incidence of asymptollliltic findings on MRI
makes imcrprelalion of patienl ,,(udies morc difficult becau\c
each imaging finding must be closely correlated 10 symp­
LOIllS Ihat can be relatively nonspecific in mallY palicllls.
MRI alone is not able 10 differentiate \ymplOmatic from
 CHAPTER I Princi ples in Assess ing Musculoskeletal Disorders 33

TA B l E I- I I
PREFFRR£D RADIOGRAP HIC VI EWS I N SKE LETAL TRAUMA

Arca Specific Views Area Specific Views

Skull POSlCroanlerior or anteroposterior Caldwell Sternum. Posteroanterior

Townes sternoclavicular Right and left anterior obliques with
Uilcral (one lateral should be upright) joinLS cephalad angle of lube
Lateral
Facial bones Waters Elbow Anteroposterior
Modified Waters Lateral
Caldwell Capitellum
Lateml
Cervical spi nc Anteroposterior Radioulnar joims A meroposlerior or posteroanterior
Coned odontoid or oflhopanlogram (forearm) Lateral
Odontoid
Lateral (cross�table or upright)
Swimmer latem! (cross-table)
BOlh obliques, when possible
Thomcic spine Anteroposterior Wrist and hand Posteroanterior
Lateral (cross-table or routine) Oblique imerna!. ex.temal. or both
Swimmer (coned to upper thoracic spine) Lateral
Navicular views. if needed
Lumbar spine Anteroposterior Pelvis, acetabulum Anl.eroposterior
L<llcral (cross-table or upright) Obliques (Judet)
Lateral {coned to L5-S I }
Sacrum Anteroposterior (tube-angled cephalad) Hip. proximal part Anteroposterior pelvis
Lateral of femur Frog·leg or cross-table lateral
Obliques
Chest Posteroanterior or anteroposterior Femur Anterol>osterior (to include hip and knee)
Left lateral (may not be possible in Lrauma) Lateral (to include hip and knee)
Lateral decubitus (pneumothorax.. pleur'c11 Ouid)
Ribs Anteroposterior or posteroanterior Distal part of femur Anteroposterior
Oblique and knee Latcml
Tunncl
Internal oblique
Shoulder Anteroposterior (internal rOlation) Tibia. fibula Antcroposterior (to include ankle and knec)
Anteroposterior (ncutml) Lateral (to include both joints)
Transscapular lat.eral (NeeI')
Axi llary
Humerus Anteroposterior (to include elbow and shoulder) Ankle Anteroposterior
Latcml (10 include both joints) Oblique (mortise)
Lateral
Clavicle Anteroposterior or posteroanterior (to include Calcancus Tangential
both joints with and without weight bearing) Lateral
FOOl Laternl
Anteroposterior
Oblique
Lateral

From Gu:;tilo RB. Kyle RF. Templeman DC: Fr(lCfU"e� ami (/islocmio//'\', 1'01 I. 51 Louis. 1993. Mosby,

asymptOmatic degenerative disc Changes (Scuderi et al. in
pres:;).
Magnetic Resonance Imaging
M R I is a computerized, thin-section imaging proced ure that
uses a magnetic field and radio·frequency waves rather than
Lhe sagittal, coronal, o r axial planes, a s well a s a n y other
oblique plane desired. The MRI can i mage neuro logi c struc­
tures and other soft tissues and can reveal disc degeneration
before any other imagi ng method. Indications for MRI are
similar 10 those for CT. M R I is superior to CT for the
evaluation of suspected spinal cord tumors or damage intra­ .

ionizing radiation. M R I can produce thin-section images in cranial disease. and various types of central nervous system
34 CHAPTER I Principles in A"essing Musculoskelelal Disorders

" IZI II"I' I I) l l (,\\\1 1 1 ' j

ASSESSMENT ABILITIES AND

LIMITATIONS OF PLAIN-FILM
RADIOGRAPHY
r------
I . Plain- if lm radiography is Ihe leasl expensive and mosl
widely ..vailable imaging lechnique.
2. Radiography offers higher spalial resolulion than any
other modalily, providing exlremely high contrast for
cortical and trabecular bone.
3. Radiography affords only a projectional viewing per­
spective.
4. Projeclion of three-dimensional anatomy onlo a 1\\'0-
dimensional film results in morphologic distortion
and superimposilion of overlapping struclures.
5. The sensitivily for trabecular bone los> is relalively
poor.
6. As much as 30% 10 50% of lrabecular bone must be
removed before Ihe change becomes perceplible on
convenlional radiographs.
7. The contrast for soft lissues Ihal are not calcified or
fauy is relatively poor.
8. Radiography cannOI directly visual ize Ihe articular
cartilage, inflamed synovial lissue, joint effusion,
bone marrow edema, or intraanicular fat pads.

(1IZIII " I' I I) I ( (,\\\1 I I "

ASSESSMENT A B I LITIES AND

LIMITATIONS OF COMPUTED
TOMOGRAPHY
I . The grealeS! advantage of CT over convenlional radi­
ography is its lomographic nalure.
2. CT provides high contrast belween bone and adjacem F I G. 1-19 Complex acetabular fraclure. A, Anlcropo,lerior
tissues and is excellent for evaluating osseous struc­ plain film. B, Axial computed tomography scan. (hum GU'lilo
lures. R H . Kyle RF. T�mplcman DC· rraC"lIln.'\ mul di,hlnllimu. \01 I Sl l.oui,
3. CT offers slightly grealer SOh-lissue contra>! than 1993. M<hhY.1
radiography.
4. Image contrasl is insufficienl lo visual ile the articular
canilage or synovial tissue or to discrimjnate between
lendonilis and tendon ruplure. cilha diagnmm. or operative planning. A "'OfHiv..ue rna..... In

5. CT reveals only Ihe surfaces of these struclures; il the hand may be a manifc..tallon of ncopla...m. congenital

does nOI disclose intra substance changes that may malformation. infection. other inOammalory proce ...... or

precede gross morphologic disruption. trauma. Infcctiou... and traumallc cau ..c... arc more prc\alcOi
111 pediatric palicllI!'I than ncopla,ia or congcmtal malfonna-
lion. The evaluation of the...e ma,...c!'l ...hould IIlclude an
a....e
. .... menl of the extent of the ...oft-u......ue. m...cou.... and

di «asc (e.g .. multiple sclerosis). M R I is especially lIseful in ncurova,cular II1volvement. Of all Ihe lIunging ImxJalllle"

identifying small di fferences among similar soft tissues and MRI i ... he..., ..uiled for ,hi... role (Jimene/. Jaramillo. Con­

surpa"es CT in Ihis regard. nolly. 2(05 ).

The evaluation of a child with a \uspccted ..oft ti"..uc mass
III the hand i.., .
1 chal lenge. Imagmg evaluation ... houkl t>egin
with radiograph... that l11a) reveal the diagno..i!'!. Further
imaging ....
· ith uhra...ound. CT. or MRI is often required for
In Ihe management of low back pain and lumbar degen­
erative kyphosis disorder!'!, paraspinal muscles are subjected
to many slUdies using ultrasound, CT. needle eleclromyog­
raphy (EMG). and histopalhologic analysis. MRI can evalu-
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 35

fA 1l 1 E 1- 1 2

I N I U RI ES ASSOCIATW WITH SKELETAL TRAUMA

Fracture Associated Injury

Bone and bone Remote additional spinal fracture

Spine Scapula fracture
Chest wall Sacrum fracture or dislocated
Anterior pelvic arch sacroiliac joint
Femoral shaft Fracture or fraclUrc-dislocation of
Tibia (severe) hip
Calcaneus Dislocated hip
Fractured thoracolumbar spine

Bone and viscera Ruptured mcscnlcry or small bowel

Chance fracture of spine Laceration of liver. spleen. kidney.
Lower ribs or diaphragm
Pelvis Ruptured bladder or urethra
Pelvis Ruptured diaphmgm F I G . 1-20 Axial image showing a right paracentral hernia­

Ruptured aona
lion of the nucleus pulposus. (From Brier SR: Prim(lr" {"(Ire orOw­
Bone and vascular
Ribs I . 2. or 3 Myocardial contusion /u'lJicl. 51 Lou i )l. 1 999. Mo�by.)

Sternum Laceration of pelvic arterial lree

Pelvis Laceration of femoral artery
Obtai third femur Popliteal ancl)' laceration
Knee dislocation

OIU 1101'1 J) I ( (, ·\ M ll I I 2 7
Adapted from Roger� IF. Hendrix RW: Evaluating the multiple injured
patient radiographically. Orillop CIi" Norlll Am 2 1 (3):444. 1990. fOR CERTAIN PATHOLOG [ C
COND [ TlONS, MAGNETIC
RESONANCE IMAG[NG [ S THE
D LAGNOSTIC PROCEDURE O f
CHOICE
O RI II O I' I Il I ( (,,\ �1l1 1 1 '>(,
I . Spinal disc disease
USES Of DISCOGRAPHY 2. Medullary tumor
3. Mulliple sclerosis
To rule out disc involvement. especially as a cause of
4. Cerebral edema
postoperative pain
5. Spinal stenosis
To detennine the appropriate level for spinal fusion
To test the potential effectiveness of chemonucleoly­
6. Metastatic disease
7. Hemiated disc
sis
8. Discilis (or infection)
To visualize internal disc anatomy
9. Meniscal lear ( fibrocartilage abnormalities)
10. Central nervous system tumor
I I . Soft-tissue tumor

ate fatly infiltration in the muscles and the fascia status

overlying the muscles. The MRI enables the examiner to
distinguish between muscle and fibrous tissue.
The ratigue or the lumbar muscles is probably one or the
mO!<lt important cau�el-, or pain in lumbar degenerative (l JU II () I' I J) I ( (, \\\11 I I .> H
kypho�is deformity because the lumbar extensors overwork
to maintain secure balance (Takcmitsu et al. 1 988).
ASSESSMENT A B [ L 1 T 1 ES NO
Experts also �uggest that weakness is a consequence.
L 1 M [ TATIONS O F MAGNETIC
rather than a cause. of low back pain. whereby pain limits
RESONANCE [ MAG[NG
movement and muscle atrophy OCCUf!<l (Slokes. Young. I . Diarthrodial joints are panicularly suitable for MRI.
1984). 2. MRI is unparalleled in its ability to depict soft-tissue
For patients who have sustained head trauma with skull detail.
fractures. MRI is an efficient way to identify the early signs 3. MRI is the only modality lhat can examine all com­
of cerebral edema. The test procedure of choice for diagnos­ ponents of the joint simultaneously.
ing metaslalic disease is an M R I scan (Table 1 - 1 3 ).
36 CHAPTER I Principles in Assessing Musculoskeletal Disorders

TA l\! [: 1 - 13

MAGNETIC RESONANCE IMAGING VERSUS COMPUTED TOMOGRAPHY

Anatomic Area Indications Recommended Procedure

Brain (including brainslcm) Inilial evaluation (e.g., demyelination disease seizures) MRt
Previous normal cr MRI
Previous abnormal CT CT or MRI*
Unchanged abnormal CT with increase in symptoms MRI
Contrast aJ lergy MRI
Acute trauma CT
Pituitary tumors MRI
Ear, nose. throat, and eye Neurosensory hearing loss (e.g., \0 rule out acoustic neuroma) CT
Conductive hearing loss CT
Cancer staging (including laryngeal cancer) CT or MRI'"
CholeMealOTna of temporal bone CT
Fractures of facial bones CT
Thyroid or parathyroid dysfunction (artcr US) MRI
Sinus conditions CTor MRI*
Orbital disease MRl or CT*
Disease of optic t:racLS and chiasm MRI
Internal derangement of lemporonmndibu,lar joint MRt
Musculoskeletal spine Lower back or radicular pain in younger person MRI
Lower back or radicular pain in older person MRI or CT*
Cervical disk disease MRt
Spinal stenosis MRt
Cervical CTor MRI*
Lumbar MRI
Tumors MRt
Metaslalic disease
Hips Early detection or aseptic necrosis MRt
Congenital hip dislocation or reduction US
Extremities Tumors, disease. or injury to muscle. ligaments. or c<lrtilage MRI
Confirmation or calcificution or rracture CT
Chest Diseases or the hi la MRI
Diseases or the mediastinum MRI or CT*
Lung disease CT
Abdomen and pelvis General survey (e.g., to rule oul !Ulnar) CT
Li\'er disease CTor MRI*
Renal cell cancer staging MRI
Prostate disease MRI. CT. or US
B ladder disease MRl orCT
Abdominal aortic aneurysm MRJ*
Other

cr. Computed tomography: MRI. mugnctlc resonunce imaging: US. ultrasonography.

*Consult r.ldiologiSi for imaging options.
From Brier SR: Primary eMf! ortlwpedicx. 51 Loui!l. 1 999, Mosby; originally councsy of Roben Goodman. MD. Soulh Sun·olk MRI. Pc. Bayshore. New
York.

The guideline ror using the imaging modalities 10 best

advaIHagc can be summaril.cd as follows: Using slate
art M R techniques with high resolulion, at lcasi lwo plancs,
fast sequences, phaSed-array coils, and established technical
parameters. M R I can answer all clillical questions. This
guidelinc applies 10 conditions treated conservatively or sur­
gically, as well as to all manifestations of degenerative spine
disense. In particul;u. only MRI can identiry abnormalities
within the spinal cord as syringomyelia or myelopathy
:schmar, 1 998),
(Krcu
of IIle Contrast A rthrography
The conventional usc of arthrography in musculoskeletal
disease involves the use of air to distend a synovial joint and
a radiopaque contrast agent to outline anatomic structures,
The injection of contrast material into the joint space results
in a radiographic outline of the cartilage. menisci, ligaments.
or synovium. Conventional arthrography is used in diagnos­
ing the scope and magnitude of orthopedic trauma to the
shoulder, wrist. knee. and ankle (Table 1 - 1 4).
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 37

TA B l E 1-14
JOI NTS TYPICALLY STUDIED WITH COMPUTED
TOMOG RAPHIC ARTHROGRAPHY FOLLOWING
TRAUMA

Joint To Observe

Knee Meniscus. cruciate and colhlleral

ligaments. hYlilinc cartilage tears,
osteochondral delects
Shoulder ROlator cuff, glenoid labrum disruption
Hip Hyaline cartilage integrity and teurs.
pro!!lhctic joint loosening
Wrist Triangular fibrocartilage, intercarpal
ligament imcgrilY
Elbow Hyaline cartilage integrity.
osteochondral defects
A n kle LigamenLous lears. osteochondral
defects
Temporomandibular Disc and condylar integrity

Adapted from GUl>lil(} RB. Kyle RF. Templeman DC: FraclI!res allli (Ii:.-
!oCll/iol1:'i, 1'01 I. 5t Loui .... 1993. Mosby. A

0 1( 1 1 1 0 1' 1 Il l l l,,\MIII I 2<)

ASSESSMENT ABILITlES AND

LIMITATlONS OF RADlONUCLIDE
•

SCANNING
I , The principal advantage of scintigraphy over oLher
imaging modalities is its ability to help in identifying
tissues or organs with abnormal physiologic Or bio­
chemica.l properties.
2, Increased skeletal uptake can be seen at sites of ele­
vated blood flow or increased bone metabolism,
3, Scintigraphy is a convenient way of surveying the
enlire skeleton for multifocal processes,

COl1lra�l-cnhanccd cartilage imaging can visualize early

degenerative cartilage lesions before substantial morpho­
lugic changes occur. The application or contrast agent can
B
he performed a� either direct or indirect M R arthrography.
Despite the advantages of indirect MR arthrography using F I G. 1-2 1 Normal bone scans. (From Earl), PJ, Sodcl DB: Prin­

intravenolllo. contrast material. direct M R arthrography has dples (lml practice of mtl.·lea,. IIU!tiicifll!. Sl Louis. 1 995. Mosby.)

gained increasing popularity il:-; a safe diagnmaic 1001 in

assessing subtle illlraanicuiar derangements. including the
evalu�lIion of articular cartilage especially in the shoulder,
the hip, the ankle. ilnd the postoperative knee (Guntern
C\ a1. 2003: Kassarjian CI al. 2005: McCauley. 2005: Schmid
CI ul. 2003),
Radionuclide Scanning
Examinations conducLed wiLh the use of nuclear medicine
techniques, including bone scans. posiLron emission LOmog­
raphy (PET) scans. and single-photon emission computed
lomography ( SPECT) scans, are valuable in diagnostic
imaging because of their highly sensitive and noninvasive
nature. Whole-body scanning for metastatic and infectious
di seases, as well as in flammatory and ischemic processes. is
possible with scintigraphy (Fig. 1 -2 1 ),
Highly active individuals (e.g.. competitive athletes) are
prime candidates for bone scanning when the diagnosis
is uncertain. A bone scan may show increased uptake or
38 CHAPTER I Principles in Assessing Musculoskeletal Disorders

the radioactive isotope consistent with a Slfess fracture

(Fig. 1 -22).
Because of the high incidence of falsc-ncgalivc radiographs
early in the course of stress fractures, additional diagnostic
imaging is oftcn indicted. Radionuclide bone scanning has
traditionally been the Lest of choice in this situation but is
being supplanted by M R I . An increased uptake observed on
a bone scan correlates with increased bone activity caused
by fatigue failure and confinns the diagnosis of stress frac­
ture (Sehils et al . 1 992).
Despite being sen�itivc. bone scanning is nOI specific
and can yield false-positive rates between 1 3% and 24%.
Additionally. localiJ.ing the precise anatomic location of
injury can be difficult (Steinbronn. Bennet!. Kay. 1994).
Bone scanning has become common in the evaluation of
child abuse. Very young chi ldren typically do not develop
stress fractures of multiple fracture sites in normal living
situations (Fig. 1 -23).

Video Fluoroscopy
Video fluoroscopy is used when a function study of the joint
is warranted. Video fluoroscopy should be used when a
biomechanical abnormality is present but is not adequately
demonstrated by plain-film stress surveys or other examina­
tion methods.
Three-dimensional mOlion visualization in the context of
clinical and biomechanical analyses of the musculoskeletal
�ystcl1l is becoming a key instrument for investigating its
complex mechani�rnJ, and the awkward characteristics
(Lcardini cl al. 2006).
Conventional inslrumented gait analysis with skin­
mounted markers has the disadvantage of measuring arte­
facts because of skin movement relative to the underlying
bones. Video fiuoro!'ocoPY i!'o a well-established mcthod of
marc accurately mca\uring knee joint kinematics by avoid­
ing the usc of skin markers. The small field of view of the
image intensifier and thc ability only to gain kinematic data
are lhe two main dbadvantagcs of this system (Zihlmann
ct .1. 2006).

Diagnostic Ultrasound
Diagnostic ultra ound, a sound wave echo study. is particu­
larly useful for evalualing soft tissues. The diagnostic ultra­
sound does not provide the same quality of image as CT or
MRI.
Diagnostic ultrasound requires high-resolution equip­
ment. including a high-frequency transducer. Diagnostic B
ultrasound perfomls well in the detection of rotator cuff tears
FIG. 1-22 Radiographic film (A) and bone scan (B) dem­
and other tendon abnormalities, as well as in identifying
onstrating Slress fracture. (From Nichola... JA, Hen-hm:!n EB: The
some metabolic disease. In cases of suspected pediatric hip
lower exm'mity mul .fpillt' in .�/}()rtf meliil'illt!, cd 4. St Louis, 1995.
disease. diagnostic u ltrasound is the recommended primary
Mosby.)
imaging technique.
Preoperative ultrasound-guided marking of calcium dcposits
significa11lly enhances the clinical re�ults of arthroscopic
removul of calciulll deposits. The success of this type of
surgery is largely dependcnl on the exact localil.ation and
removal of calcium deposits. Complete removal of calcium
 CHAPTER I Principles in Assessing Musculoskeletal Disorder.
• AS'icssment of ftexion and extension dynamic
•
A B
FI G 1-23 A, Whole-body scintigraphy. B, Normal bone
scan is shown for comparison. (Fmm Klippel JH. Dieppc
Rht'lIInuw!og\', "01 1·2. eel 2. London. 1 998. Mo�by.)
1l1�l l l ll l' I I) 1 1 (,\\\1 I 1 ,(I
ASSESSMENT A BILIT I ES AND
L I MITATIONS OF
ULTRASONOGR APHY
I . U ltrJsonography offers direct multiplanar tomogra­
phy without any need for image reformatting.
2. U ltrasonography can also provide i mages in real time,
without any exposure to ionizing radiation.
3. The modality is inexpensive and widely available.
4. Ultrasonography offers relatively good soft-tissue
contrast and is panicularly effective at helping
to identify fluid collections such as bursitis and
abscesses.
5. Ultrasound waves cannot penetrate bone.
dcro�lt... correlatc!'! with good or excellent clinical rcsult\
c Porccllini cl ::II. 2()().l: Rupp. Scil. Kohn. 2(00 ).
Identlrying the COUI"\C of the calcium dCPQI;it i\ therefore
extremely importanl. The prescnce of a calcium dcpo\lI with
an atypical cour\c and location more proximal 10 the joint
complicates the opcmlion c\'cn further Failure to locate the
calcium dcpo.. 11 can make the ...urgical process extremely
fnlslratmg and may rcsult in a vcry long operativc time
( Kayscr ct al. :W(7).
___ 39
_ _.....
IIOX 1·4
STRENGTHS AN D L IM ITATIONS O F
MYElOGRAPH I C ST U D I E S
Strengths
Studies 01" the subarachnoid space arc poss.ible.
Inlraarachnoid lesions are shown.
Demarcation of multi-disc levels is shown.
Information on surgical scars is provided.
arc possihle,
Limitations
Lesions removed from outside of the thecal sac can be
missed.
Study variations are problematic.
Detail shown in the dorsal spine is poor.
Postoperative studies arc impossihle to read with accur.J.cy.
Testing. procedure is invasive.
From Brier SR: Primlln- cart' onho/H·t!in. St Loui�, 1999. Mosh)'.
Myelography
Traditional myelographic techniques involve Ihe inlroduc­
lion of 'imall amounts of water-soluble contrast medium into
PA the subarachnoid space, either through a lumbar approach
below the level of the conus medullaris or at the level of
C I -C2 through a posterolateral approach. Standard films of
the spinal canal are made to determine the presence or
absence of a filling defect. In cases of acute spinal trauma,
myelography may be used in conjunction with CT (Fig.
1 -24).
Myelography remains valuable in evaluating intrinsic
spinal cord lesions, nerve root lesiom and dural tear!) asso­
• .
ciated with severe trauma ( Box 1-4).
Depending on patient selcction and therapeutic strategy. the
role of plain CT and MRI. as well as myelography comhlncd
with myclo-CT. in the diagnmtic evaluation of dcgenerative
change\ of the ,;pinc is judged diffcrently ( Krcl.t\chmar.
1 998).
In paticnt, with di\k dlsca\c. plain-film cr for initial
diagnmtic examination is rccommcnded. if the complaints
are non\pccific (Thornbury ct al. 1 99 1 . 1 993).
If the clinical finding:o, \uggest a herniated dis�. MRI
should he given prcfcrence ovcr myclog.raphy comhined
with myclo-CT. Thc U\C of non ionic contrast media without
meningeal irritation or neurotoxicity ha� reduced the mor­
bidity of myelography < Krett...chmar. 199K).
Thermography
Using temperature differentials of the body. Ihermography
illustrates neurovascular changes in injury or dh�ease. Ther­
mograms do not provide speci ic
f information regarding the
cause of nerve fiber irritation (e.g .. herniated disc. scar
tissue_ myospasm).
Reflex sympathetic dywophy is pan of a spectrum of
sympathetically mediated pain syndromes that usually occur
40 CHAPTER I Principle> in As;essing Musculoskeletal D i sorders
F I G . 1-24 Lumbar myelogram ( A ). with computed tomog­
raphy aX1i.I1 imuge (8) through the T 1 2 body. (hom GU... lilo RB.
Kyle RF Fm('tllrt'\' rllld d/\lowtfOlI\, vol 1. SI l.oui ... 1�J3. �10,hy. )
in an extremity after a \ccm i ngly minor injury or
procedure .
Even Lhough certain ...imilarilic... cxi--I helwccn aculccomplcx
regional pmn \yndromc\ (n:tlcx \yrnpathclic dy\lrophyJ and
patient... \\ IIh acule trauma. detailed illvc\tigauol1 or the.....:
...ign ... n!\ic.lh ...lriking di fference... . The dinical ... imi lnril)­
compn ...c\ pam. hypcralgc...ia. and ..,ome prc... umahly auto·
nomic di,turhancc\ (edema and ,kill tcmpcnllurc change..,),
(\1(l 11(l1' 1 1) 1 ( (,\\\ 1 ' 1 I ; )
ASSESSMENT A BILITIES AND
LIMITATIONS OF
I- __ T
--=
....:.
H .E
.:...: RMOG
::..:. ..: RA!'.H_
Y_
I . The thermographic examination is conducted with the
use of contact liquid cl)'slal detectors or electronic
infrared sensors.
2. Thennography is extremely scnsiti\'c to Ill icro\'ascu­
lar changes in the skin.
3 . ThemlOgraphy IS excellent f"r differentiati ng between
a neurologic and vascular abnormality.
4. Thennography has a greater degree of 'cns l l l \ lIy in
documenling neurovascular abnormality than any
other imaging sy\lcm.
5. Thermography has a greater degree of spec i ficity of
image than mdionuclide hone scan.
6. Thermography has a lesser degree of speci licity of
Image resolution than CT or ,\1RI.
Motor and trophic \ymptom.... ho\\c\cr. characlcri/c mmplex
regional pam ,yndromc, hut arc not found after acute
trauma. Thc\c latter 'ymptom, ob\iou,l) need time to
de\cJop. and the durallon of d .. ,ea,e clear!} "::panuc"
complex regional pam ,,)ndrome' (\\ccb) ,\Ild trJlllna (da)"
(811-)"'lell1 ct al. 2000 ).
Electrodiagnostic Testing
Although electrodiagnostic testing provides valuahle infor­
mation. it docs not stand alone as a diagnostic entity (Table
I - I S). The data obtained must be correlated w i lh the phySi­
cal examination findings and case hi\lory.
Electrodiagnostic testing can potentially dliTerent i ate
asymptomatic dh
, k hcmialions rrom symptomatic ones. A
minimal amount of dencn'aLion can occur in asymptomat ic
..,pines.
With �urface measurement of motor nerve conduction.
velocity provides a "aluable anci llary procedure In the diag­
no�is of various pcriphcral nerve lesions in both thc upper
and lowcr extrcmities. This form of testing involves stimu­
lating a peripheral ncrve at two ...eparatc po...itions along it ...
COUfl)C and recording the action potentials obscrved on an
oscilloscopic scrcen. Slow conduction time'> indicate nCf\'C
entrapment syndromes across the poi III HI whir h thc il11puhc�
are delayed.
Thc electrical rcsponses of nCf\OllS system sensory trad"
\ urgical are SOIl1l11o.\ellsory-e\'okl'l1 potentials (SSEPs). SSEPs evalu­
atc varioul) pathologic variation!) from the peripheral nene
through the spinal cord to the \omatoscll..,ory region of the
brain. SSEPs assess discascs of thc "'pinal cord. trauma
to thc spine. ncuromuscular diseasc. and demyelinating
disorders.
U,ing needle electrodes, needle EMG is \\ idely u,ed to
diagnosc nCf\'C root le... ions at the level of the 'pille. EMG
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 4,...
1 _----'

lAll L I I 1 5

STRENGTHS A N D liMITATIONS O F ELECfRODIAGNOSTIC TESTING

Testing Modality Strengths Limitations

Nerve conduction velocity Helpful in ruling OUI peripheral cntrapmcni neuropathic
conditions (c.g., prolonged latencies exhibited in
carpal tunnel syndrome, tarsal tunnel syndrome) lind
ulnar neuropathic variations
F waves Provides screening for lale mOlor response with distal
sweeps staning at the fool
l-I reflex Equivalent of ankle join! reflex: evaluates
monosynaptic reflex with sensory and mOlor S I
function
SSEP, Helpful in documenting sensory pathway dislUrbances
in proximal neural injury and central conduction
delays, as in myopathies and multiple sclerosis
Needle EMG Useful in assessing conductivity of ncuntl tissues:
helpful in determining sile and severity of lesion;
may be helpful in carly assessment of recovery.
screening for fibrillation potentiab. and signs of
denervation from nerve rOOI compre�sion disorders
Provides imperfect sensitivity; limiled locali/..alion
and determination of injury severity; Liming of
study an imponant factor
Evaluates motor reflex only: possibly evailimes
abnonnal findings only in lhe presence of
multiple-level injury
Provides assessment of S I nerve root only
Offers imperfect localization: findings arc rarely
abnonnal if results of other electrodiagnostic
tests within nomlal limits
Unable to detect denervation potentiab for 14 to
28 days aftcr injury: provides imperfect
5.Cnsitivity: study timing an imponant factor:
proxinu11 lesions sometimes inaccessible
anatomically: effectiveness reduced after
surgery

EMG. Eh..'Ctmmyography: SSEPs. .;omutoscmory-c\lokcd potential!..

Adapted from Brier 5R: Priman' ('lirt' ortl/Of1l'dic.�, 5t Loui!., 1 999. Mo<,hy.

llltl l llll'l nil l,,\'\\ ll l I \2

ASSESSMENT A BILlTlES AND

LIMITATIONS OF NERVE
CONDUCTlON VELOCITY
I . Studies of nerve conduction velocity (NCV) can rule
out peripheral neuropathic conditions.
2. Routine NCV tests are not specific for conditions
such as radiculopathy, but they may be helpful i n
cases o f chronic pain that have a questionable spinal
origin.

F I G . 1-25 The IMEX portable Doppler (righl). audibly

lllU IIll l' l llIl t, " I ll I I II monitors pulses in noisy environments when palpation is

ASSESSMENT A BILITIES AND queslionable or not possible or when the pulse is especially

L1 MlTATlONS OF weak or rapid. The Doppler also aids in the assessment

ELECTROMYOGRAPHY of circulation distal to fractures, burns. and other injuries

Lo quickly determine the extent of injury. Transmission
I. Electromyography (EM G) shows fibrillation poten­ gel (Iefl) is used to couple the Doppler head to the skin
tials and possible motor unit changes in denervated surface and eliminate air gaps that can degrade sound
muscles. transmission.
2. Denervation of paraspinal muscle, indicates that the
patient has a lesion at the nerve root level.
3. The usual finding of needle EMG in a palient who has
dorsal root disease is normal.
4. It does not provide any information with respect to
the locus of injury (e.g., root, nerve, muscle) and, in
fact, often rcneclS associated tissue injury rather than
neurovascular dysfunction.
42 CHAPTER I Principles in Assessing Musculoskeletal Disorders
differentiates a central spinal lesion from a peripheral neu­
ropathic condition. Resuhs of the procedure are accurate i n
differentiating disease o f a neuromuscular origin.
Doppler Ultrasonic Vascular Testing
Doppler vascular testing allows the assessment of pulses in
noisy environments or when pulses are weak. This lest is
efticient when palpation of a pulse is questionable or not
possible. The Doppler instrument aids in the assessment of
circulation distal to fracture sites. burns, and other injuries
lhal potentially compromise vascular tissue, quickly deter­
mining the extent of injury (Fig. 1 -25).
Laser Doppler flowmetry is a valuable noninvasive method
for investigation of the very early skin vcnoartcriolar dys­
functions. for evaluation of focal autonomic dysrcgulation
and skin vasomotor abnormalities in patients with Raynaud
phenomenon. Laser Doppler-recorded vcnoartcriolar reflex
testing i� a simple procedure and an adequatc addilional
diagnostic 1001. which contribute� to diagno�c Raynaud phe·
nomcnon and differentiate primary frolll secondary Raynaud
phenomenon (Stoyncva. 200�).
 CHAPTER I Principles in Assessing Musculoskeletal Disorders 43

C R I I I CA L 1 11 1 N 1\.1 N (;
I . In the complaint history of a musculoskeletal condi-
lion, what essential points hould be included for
proper history taking by an experienced examiner?
2. Name the five essential steps in drawing a working
diagnosis for your patient.
3. Name the Cr;t;cal 5 questions in orthopedics.
4. Describe lendrassik maneuver.
5. You have a patient who is complaining of unrelenting
spinal pain who demonstrates full and pain-free range
of motion. What two problems should you consider
with this presentation?
6. Describe the difference and what information can be
obtained from the five rung test and the max;mal
stalic grip when using a Jamar dynamometer.
7. What are the significances of the clinical findings of
the static grip test and the REG test?
S. How are the two tests penormed?
9. How would you describe the presentation of a patient
with scleralogenous pain?
10. Why is serial radiography useful i n a patient with
rheumatoid arthritis?
I I . What area or areas would you monitor?
1 2. How Frequent should radiography be used?
1 3. You have just diagnosed a case of AS. How frequent
should you penorm serial studies of this patient?
14. What areas should be monitored?
1 5. A question of causation arises in a child with multiple
complaints. What imaging procedure would you rec-
om mend for this child?
1 6. SSEPs are useful in the evaluation of various patho-
logic conditions. What part of the nervous system is
evaluated with this process?
44 CHAPTER I Principles in Assessing Musculoskeletal Disorders
B I B L I OG RA P H Y
American Medical Association: Guides 10 the evaf,utl;Ofl of penncmelll
impairmen', cd 4. Chicago. 1 993. American Medical Association.
Anderson KN. Andcn.on LE: Mosby 's pocket dictionary oj medidne,
mln.ing, &. alfiell Ilea/th. cd 2. SI Louis. 1 994. Mosby.
Ar..tbi A Cl al: Discriminative ability of dual-encrgy X-my absorpliomctry
. lection ill i dcntiry ing palienls with oSlcoporOlic fr'dclurcs, BOlle
site 'iC
40(4): 1060. 2007.
Ashford RF. Nagclburg S, Adkins R: Senshivity of the Jamar dynamometer
in detecting submaximal grip eITort. J Hand 5/lrg 2 1 (3):402.
1996.
Atkinson G. Nevill A. Hopkin!> WG: TypicAl error vers u::; limib of agree­
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 C H A PTER 2 Assess ing Cardi nal Musculoske letal Sym ptoms and S ig n s 69

TA B U 2- 1 2
TREMOR C LAS S I F I CAT I O N

Cause Type and Rate of Movement Description

Anxiety Fine, rapid. I () to 12/scl' I rregular, variahle

I ncreased by attempts to move part; decreased by relaxation of part
Parkinsonism Fine, regular. or coarse. 2 t o 5/sec Occurs at rest
May be i n h i bited by mov e me nt
Involves flexion of fi nger and thumb pill rollillg
Accompanied by rigidity. cogwheel phe n ome n a , brady k i nesia
Cen:hcllar tremor Variable rate Evident o n l y on mo ve m c n t (most prom i nent on linger-to-nose test)
Dysmetria (seen when patient i s asked to pat rapi d l y ; pats are of unequal force
and do not all arri ve at same point)
Essential or seni Ie Coarse. 3 to 7/sec I n volves the jaw. sometimes the lOngue, and sometimes the entire head
Metabolil' Disappears on complete relaxation or in re s pon se to a lcoho l
Yariahle
Patient is obv iously i l l ; if i l l ness i s a res u l t of hepatic fai' l u rc, patiel1l w i l l have
other signs, such as palpable l i ver, spider nevi

From Barkauskas YH et al: Health & physical assessmefl/. ed 2 , St Louis. 1 998. M osby.

Cramps and Spasm

O RI H O P I D l l' ( ; ;\ , \HJ r 2 I I
Muscu lar spasm, or tremor (Table 2- 1 2), may occur at rest
or with movement. S pasms and tremors occur in the normal GAIT
ind i vidual with metabo l ic and electrolyte a l terations. Cramp­
Gait impairments of predominant neurologic origin
ing is a common complaint after excessive sweati ng and
include the following (in descending order of
subsequent hyponatremia, hypocalcemia, hypomagnese­
frequency):
mia, or hyperuricemia.
I . Di sorders of the corticospinal pathways (spasticity )
Exercise-associ ated muscle c ram pin g is a pai n fu l . involun­
2. Basal gangl ia ( parki nsonism)
tary contraction of skeletal muscle that occurs i mmed i a tel y
3 . Cerebel l u m and connections ( ataxia)
after e x e rc i se . Any athlete who e x h i bi t s repeated epi sodes
4. Cerebral cortex (gai t aprax ia)
of muscle spas ms should u n d ergo a comprehensive h is lOry
5 . Neuromuscul ar system ( weakness)
and p h y s ic al e x a m i n ation and. in most cases, l aborato ry
6. Sensation (atax ia)
studies to evaluate e l ectro l y te s . Athl etes should a l so have a
u r i n a l y s i s to c h ec k for blood or myoglob i n . The i n i ti a l
history shou l d i ncl ude questions pertai n i ng t o h ydra t io n
status, frequency of s t ret ch i n g . and the use of ergogenic
s upp l eme n t s s uc h as stero id s or creat i ne . Questions to define
the athlete's me d i c a l h i story should i n q u i re about how the Trousseau sign i s demonstrated by i nflating a sphygmo­
muscle crampi ng relates to temperature, d iet. fa m i l y history, manometer around the wrist area of the left hand to above
u r i ne color changes (myog l o b i nuria), and how l o ng the systolic blood pressure for 3 mi n u tes while observ i ng the
symptom� last ( Nad l er et ai, 2004). hand. Typ ical carpal spasm, which relaxes approxi mately 5
seconds after the cuff is released, is considered a positive
Tetany Trousseau sign.
Hypocalcemia and hypomagnesemia often cause the Tetany i s m o s t c ommo n l y caused by h ypoca l c e m i a . Low
invo l untary spasms of s keletal m uscle, which resemble levels of free or ion ized e x trace l l u lar c a l c i u m reduce the
cramping. Tetan ic cramps can be el icited by repeatedly per­ normal transmembrane pote n t i a l of the nerve by i ncreasing
c u ss i ng the motor nerve, which leads to a muscle gro u p so d i u m conductance, thus red u c i n g the threshold req u ired to
contraction-cramp-spasm at frequenc ies o f 1 5 t o 20 per cause depolarization. Normal serum ion ized c a l c i u m l evels
second. Chvostek s ign is the spasm of fac ial muscles pro­ range from 5.9 to 6.5 mg/d l . Levels fa l l i n g be l o w 4.3 mgldl
duced by tapping over the facial nerve near i t s foraminal can cause tetany. H y poca l cem ia i s observed in h y poparathy­
ex it. Chvostek s ign may also occur w i th normocalcemia, as roid i s m , v i ta m i n - D deficiency, m a l ab s orpt i o n s y n dromes.
wel l as w i th h y pocalcem ia. acute pancrea t i t i s . m a l i g n ancy, sep s i s . and drug effect.
Patients w i th hypocalcemic seizures demonstrate marked Hyper venti lat i o n lead i n g to respiratory a l k a l o s i s and sec­
Chvostek sign, positive Trousseau sign, sweaty hands, and ondary reduction of ionized c a l c i u m may prec i p i tate tetany
hyperreflexia (Ahmed et ai, 2004). (Freeman, M ichae l . R ob e rt . 2003).
70 CHAPTER 2 Assessing Cardinal Muscu loskeletal Symptoms and S i gns

Impairment of Gait
Finding a spinal or lower ex tremity orthopedic or neurologic
di sorder that does not produce abnormal i ties of gait a t some
time during i ts course i s d ifficult.
Gait disturbances a fter a stroke a r e multifaceted a n d hence
O RI I I O I' I D I C l,A,\\ lJl 1- 1 -1-
IMPAIRED MICTURIT I ON
Localization of impaired micturition depends on the

must be studied from multiple perspectives. B iomechanical following:

measurements such as temporal distance parameters, kine­ 1 . Loss of bladder sensation

matics, kinetics, mechanical energy, and energy costs, as 2. Perineal sensory loss

well as electromyography, can evaluate the behavioral 3. Patulous anal sph i ncter
profile of gait and reflect CNS adaptation with respect to 4. Absence of the bulbocavernous and anocutaneous
internal and external demands. Electrophysiologic measure­ reflexes

ments such as stretch reflex, H-reflex, and cutaneous reflexes 5 . Sensory, motor, and reflex changes in the lower
can evaluate the integrity of spinal cord functions during gait extrem ities

and indirectly assess the integrity of the descending control

system (Lamontagne, Stephen son, Fung, 2007).

B1adder Control
Incontinence and other disturbances of urinary bladder fu nc­ bilateral-needle e1ectromyographic examination of the
tion are occasion al l y the fi rst man ifestation of d isease of the externaI anal sphincter and sometimes of the bulbocaverno­
spinal cord, as well as the rest of the nervous system. The sus muscle needs to be considered first. Detection of spon­
physiologic mechanism of micturition is complex. The terms taneous denervation activity, most appropriately in the bul­
atonic bladder and spastic bladder are no longer useful i n bocavernosus muscle, is common in the interval from 3
descri bing different levels of neurologic i n v olvement weeks to several months after a lower motor neuron i njury
because they are related mainly to l ocal factors i n the bladder ( Podnar, in press).

wall. A n associated history of erectile dysfunction or rectal

Compressive lesions to the cauda equina or conus medullaris incontinence should c learly suggest the presence of a
are a common cause of neurogenic lower urinary tract dys­ common neurogenic cause for urinary i n continence. The
function, although more peripheral lesions may also cause additional presence of sacral pain should suggest tumor in
sacral disease. [n patients with suspected focal sacral disease, the sacral region.
 CHAPTER 2 Assessing Cardinal Musculoskeletal Symptoms and S igns 71

CRt n e A L T H t N Kt N C

I . What are the five groups of signs and symptoms dif­ 9. What are the two most common tumors of the dig its
ferentiating muscu loskeletal complaints? of the hand and on the dorsum of the foot?
2. Why can articular or periarticular pain radiate widely 1 0 . A hel iotropic rash and Gottron papules are character­
and be fe lt in a spot di stant from its originating istic and possibly pathognomonic cutaneous feature
tissue? of what condition?
3 . What typical sensations differentiate pain with nerve I I . Where can Gottron papules most commonly be
entrapment, vascular compromise, and articular or found?
joint involvement? 1 2 . The Leeds Assessment of Neuropathic Symptoms I
4 . In listening to a patient's description of pai n , i . e . , and S igns i s used in the assessment of what type of
when present, what relieves i t , what makes i t worse, conditions?
and what improves it, pain at rest, night, or with u se 1 3 . You have a very athletic patient with reoccurring
suggests what kinds of problems? episodes of muscle cramping with exercise . What
5 . What is the leading cause of accidental death in older would be your immed iate action steps for this case
adults? presentation?
6. What subgroup of patients is at high risk of develop­ 1 4 . Gait impairments from d isorders of the corticosp inal
ing chronic lower back pain ? pathways are mani fested by what?
7. What four issues are important in assessing a patient's 1 5 . Gait i m pairments from the cerebe l l u m and its
disability? connections are c haracterized by what?
8. After thoroughly examining the patient's painful part,
you have doubt of the source of the symptoms. What
would your next step be?
72 CHAPTER 2 Assessing Cardinal Musculoskeletal S),mptoms and Signs
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