History And Physical Examination

The key to a proper history and physical examination is to have a standardized plan that accomplishes the needed specific objectives.

Quantitate the Morbidity

Use a scale value of pain, function, and occupation to understand how sick the patient is. Converse in detail with the patient to hear the inflections and manner of pain description. Detail the time of disability and the time of origin of the pain.

Delineate the Psychosocial Factors

Know what psychological effect the pain has had on the patient. Know the social, economic, and legal results of the patient's disability. Understand what can be gained by his or her being sick or well. Derive an understanding of what role these factors are playing in the patient's complaints.

Eliminate the Possibility of Tumors, Infections, and Neurologic Crisis

These diseases have a certain urgency that requires immediate attention and a diagnostic and therapeutic regimen that is very different from disk disease.

Diagnose the Clinical Syndrome

• Nonmechanical back and/or leg pain: inflammatory, constant pain, minimally affected by activity, usually worse at night or early morning.

• Mechanical back and/or leg pain: made worse by activity and Valsalva maneuver and relieved by rest.

• Sciatica: predominantly radicular pain, positive stretch signs, with or without neurologic deficit.

• Neurogenic claudication: radiating leg or calf pain that is worse with ambulation, negative stretch signs that are worse with spine extension and relieved with flexion.

Pinpoint the Pathophysiology Causing the Syndrome

Three important determinations are listed:

1. What level? Which neuromotion segment?

2. Which nerve?

3. What pathology: What is the exact structure or disease process in that neuromotion segment that is causing the pain?

The history and physical examination are the first step in determining the clinical syndrome. Some key factors are the following:

• The time of day during which the pain is worse.

• A comparison of pain levels during walking, sitting, and standing.

• The effects of Valsalva maneuver, coughing, and sneezing on pain.

• The type of injury and duration of the problem.

• The percentage of back versus leg pain. We insist on getting an accurate estimate of the amount of discomfort in the back and legs. There must be two numbers that add up to 100%.

The physical examination should address the following:

• The presentation of sciatic stretch signs.

• The neurologic deficit.

• Back and lower extremity stiffness and loss of range of motion.

• The exact location of tenderness and radiation of pain or paresthesia.

• Maneuvers during the examination that reproduce the pain.

The history determines whether it is an axial (back pain) or extremity (leg pain) problem. What is the exact percentage of back versus leg pain? Is the pain made worse by the mechanical activity or is it a constant resting pain? Is the pain worsened by maneuvers that increase intradiskal or intraspinal pressure? Is there significant night pain?

Classic radiculopathy causes radicular pain radiating into a specific dermatomal pattern, with paresis, loss of sensation, and reflex loss. The radicular pattern of the pain and neurologic examination determine the nerve involved.

The classic history of radiculopathy resulting from a disk herniation is back pain that progresses to predominantly leg pain (Fig. 43-3). It is made worse by increases in intraspinal pressure such as coughing, sneezing, and sitting. Leg pain predominates over back pain and mechanical factors increase the pain. Physical examination shows positive nerve stretch signs. A dermatomal distribution of leg pain that is made worse by straight-leg raising, the sitting or supine position, leg-straight

Figure 43-3 Herniated disk (arrow) leading to radicular symptoms in a 36-year-old golfer.

foot dorsiflexion, neck flexion, jugular compression, and direct palpation of the popliteal nerve or sciatic notch is characteristic of radiculopathy. A source of radicular pain not found in this description is that caused by spinal stenosis. Spinal stenosis usually lacks positive nerve stretch signs but has the characteristic history of neurogenic claudication (i.e., leg and calf pain produced by ambulation). Pain that does not go away immediately on stopping is made worse with spinal extension and is relieved by flexion. The pain progresses proximally to distally.

The pain drawing is a major help in accomplishing the objectives of the physical examination. Each patient completes the pain drawing using a rating system, which distinguishes organic from psychological pain fairly well. It also helps localize the symptoms for future reference with pain reproduction studies such as with diskography and postoperative evaluations.

The initial history and physical examination determine the aggressiveness of the diagnostic and therapeutic regimen. The morbidity rating and the length of time that the patient has had the problem are important parts of the history and physical examination that help determine the aggressiveness and inva-siveness of the diagnostic plan. The leg pain versus back pain ratio is an important factor in determining which diagnostic tests are indicated. Leg pain leads to tests for nerve function and obstructive pathology such as electromyography/nerve conduction, myelography, contrast computed tomography, and magnetic resonance imaging. Back pain evaluation includes at times bone scan, magnetic resonance imaging, and diskography. The clinical syndrome should be divided into predominantly mechanical pain, axial pain, and leg pain. An appropriate treatment program can begin, based on the initial evaluation.

Most athletic injuries to the lumbar spine fall under the category of mechanical, axial, back, or leg pain. Within this category, a number of different syndromes exist:

1. Annular tears of the intervertebral disk, usually a loaded com-pressive rotatory injury to the lumbar spine producing severe, disabling back spasm and pain. The pain is usually worse in flexion with coughing, sneezing, straining, upright posture, sitting, and with any other situations that increase intradiskal pressure. There may be referred leg pain, low back pain with straight-leg raising, and anterior spinal tenderness. Annular tears can be produced with as little as 3 degrees of high torque rotation.16 Facet joint alignment that protects the disk from rotatory forces may lead to facet joint injuries as the annulus fails in rotation.

2. Facet joint syndrome, more typically occurring in extension with rotation, reproduced with extension rotation during the examination. This may present with a pain on rising from flexion, with a lateral shift in the extension motion. Point tenderness in the paraspinous area over the facet joint occurs and may be associated with referred leg pain.

3. Tears of the lumbodorsal fascia and muscle injuries and contusions present with muscle spasm, stiffness, and many of the characteristics of facet joint syndrome in annular tears.

4. Sacroiliac joint pain and pain in the posterior superior iliac spine. The most common referred pain area for pain from the annulus in the intervertebral disk and the neuromotion segment of the spine is across the posterior surface of the ilium, which includes the posterior superior iliac spine and SI joint. Sciatic pain can hurt in the sciatic joint area as well as the sciatic notch and buttocks. While injuries can occur to the SI joint, the vast majority of syndromes presenting with SI joint pain are thought to be the result of referred pain from a neuromotion segment in the spine.

The most important thing to be done with the physical examination of the athlete is to demonstrate what types of motions reproduce the patient's pain. Where exactly is the tenderness present? What deformity is present in the spine? If there is a lateral shift, in which direction? The chief advantage that physical therapists have in the treatment of the athlete with lumbar spine pain is the hands-on approach directed specifically to motions and activities that produce and relieve the pain. Local modalities can be directed specifically to localized areas of inflammation and pain. Treatment of referred pain areas through localized treatment in the area of the referred pain plays a major role in the relief of symptoms and return to performance. Therefore, techniques of treatment of referred pain should be understood and used. This may vary from injections of local anesthetic, cortisone injection, transcutaneous electrical nerve stimulation units, ultrasound, or ice.

Another important diagnostic category in these patients is to identify areas of contracture and weakness on the physical examination. The physician and therapist can make the diagnosis by carefully examining the patient for areas of muscle atrophy and loss of range of motion. Some very sophisticated testing and dynamic electromyographic function has identified localized areas of weakness in the shoulders of pitchers as well as in the abdominal musculature of baseball pitchers.17 There is a great deal of skill involved in the physician being able to recognize these deficiencies in the physical examination and design a rehabilitation program to correct them.

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