The examination includes the head; cervical, thoracic and lumbar spine; TMJ; shoulders; arms; forearms; wrists and hands. From the historical data, the examiner can get some indication of the mechanism of injury, tissue site, and possibly the origin of the symptoms.
Doctors often concentrate on the site of the patient's pain. This is a grave error and should need no further explanation. Clearly, the concepts of pain being referred, somato-somato responses, viscerosomatic responses, or even sociopsychological pain is something that should be a part of each doctor's thought process when examining a patient and working towards a diagnosis and treatment regime.
Doctors tend to divide the examination of the spine into cervical, thoracic and lumbar regions; clinical entities as separate and distinct as possible from each other. This is a mistake. The entire spine is closely interrelated structurally and functionally -- a whole person with a whole spine. (The reader should be aware of the works of Drs. Hammer and Roth for more detail on the integration of fascial planes. See the April 5th issue of DC.)
The cervical spine may be symptomatic because of a thoracic, rib cage or lumbar dysfunction and vice versa. Sometimes treating the lumbar spine will relieve a cervical spine syndrome or dysfunction, or proper management of the cervical spine will relieve low back pain.
If the patient slouches in a chair during the examination and loses normal lordosis, cervical spine motion is clearly diminished. During the examination of the cervical spine and occiput, the patient must sit maintaining the correct relationship between the postural muscles (tonic) and the phasic muscles (see previous parts of this series for tonic versus phasic muscles). Observing the patient's posture, movements, facial expressions, excursion from sitting to standing posture and gait provide the doctor with clinically important data.
Observe the patient walking. A histrionic gait is indicative of an exaggerated condition. Watch the patient carefully when moving from sit to stand to supine and prone positions, as compensatory or adaptive motions may lead you to the correct anatomical area and subsequent area of the patient's pain generator. Look for symmetry of supraclavicular fossae; sacral base-level fullness; pelvic tilt; asymmetrical overload syndrome; right and/or left asymmetrical overload syndrome; equality of height of iliac crests and of the scapula; forward or anterior head carriage; lordosis, kyphosis and scoliosis; the long or short leg; and foot flare postures as the patient walks. The patient sitting in a chair, bobbing the head about while talking or gesturing with the head and neck has little or no pain from the structures of the cervical spine.
As the patient walks to the examination room, observe how the head is held and how they move in a harmonious relationship with the arms and legs. The head and neck are normally held perpendicular to the floor, not held stiff, rotated or tilted to one side, nor are the head and neck held in a position of flexion or extension or anteriorly placed far from the normal. The neck may be held in an asymmetrical posture. Observe whether the deformity is a pure lateral list or whether rotation is also present. If pain is present, the deviation can be either toward or away from the painful side. Careful inspection/observation may disclose a compensatory thoracic curve. What's interesting is that all of the above are observed without touching the patient, a mountain of clinically relevant data which will make your examination far more complete and thorough.
The neck is inspected for normal landmarks such as the hyoid bone. (Recall that the posterior belly of the digastric is attached to the posterior mastoid sulcus and that occiput dysfunction could lead to abnormal stabilization of the hyoid bone, resulting in abnormal tracking of the condyle down the slope of the articular eminence.) The thyroid cartilage and gland are palpated and moved to the side so that deep palpation of the longus colli and capitus can be completed. The first cricoid ring, pigmentation and other skin lesions and conditions are palpated and noted. The osteoporotic patient can have very thin skin: patients with neurofibromatosis have light brown pigmentation (like cafe au lait). Palpate any area that looks suspicious; swollen, tender or hot areas need your attention. Increased skin temperature denotes increased vascularity, usually inflammation. (For a detailed understanding of inflammation, the reader is encouraged to read Clinical Nutrition for Pain, Inflammation and Tissue Healing by Dr. D.R. Seaman,DC, located in the Preferred Reading and Viewing section of Dynamic Chiropractic.) Hyperemia occurs in a rapidly growing neoplasm. Assess bulk and tone of muscle while remembering which is tonic and which is phasic. Any alteration in these is indicative of postural compensation and/or biomechanical abnormalities; it is your job to find them.
Deformity is easy to detect, but make sure you look for it! If pain is present, abnormal gait is characteristic and compensatory. Asymmetry of facial expression usually accompanies long-standing or acute gait compensations as a prevention attempt to avoid pain.
Observing the posterior chest wall and thoracic cage motions during normal breathing can lead to a visual finding of asymmetrical, increased and/or labored breathing rhythms. Observe the scapulae for its placement on the rib cage. Cervical dysfunction, whiplash-type accidents with involvement of the longus colli and capitus groups may be a cause of displacement of flaring of the scapula and an inability of the trapezius muscle to shrug the shoulders. One shoulder higher than the other may be caused by occupational considerations or scoliosis or, in the absence of scoliosis, may be a function of leg length discrepancies.
Scapular winging is, of course, a part of every doctor's visualization of the patient. Increased thoracic kyphosis in children and in asthenic, thin adults results in a very prominent inferior angle of the scapula. Atrophy of the infraspinatus muscle is observed and palpated while keeping in mind that the possible causes include rupture, myopathic lesions, trauma, suprascapular neuritis or severe arthritis of the acromioclavicular joint or glenohumeral joint. Recall that joint dysfunction of the acromioclavicular joint will most assuredly create a dysfunctional state at the sternoclavicular joint and may present as a large swelling with significant pain on glenohumeral and acromioclavicular motions. Remember to include conditions such as Paget's disease which will often present with clavicle enlargement.
Palpation of the anterior structures of the neck begins with the hyoid bone. The hyoid bone is above the thyroid cartilage and at the level of the C3 vertebra. The hyoid is shaped like a horseshoe. With the index finger and thumb, palpate the ends of the hyoid and instruct the patient to swallow. Note that the hyoid moves up and then down with this activity. Palpate the anterior belly of the digastric and, while asking the patient to open their mouth, feel for the contraction of the digastric and mylohyoid muscles as they depress the jaw. Note the tracking of the condyle as it moves down the slope of the articular eminence. The thyroid cartilage has a superior notch and a flaring upper portion. The upper border of the cartilage is at C4, with the lower border at C5. Just below the inferior border is the first cricoid ring. This is at the level of C6 and is palpable. Remember that this is the upper border of the trachea. Scars located just below this region may be indicative of an emergency tracheotomy. The cricoid ring also moves with swallowing.
About two or three cm lateral to the first cricoid ring, the anterior tubercle of the transverse process of C6 can be palpated. (It is deep, but easily palpable.) The carotid arteries are adjacent to the tubercle and their pulse should be palpated. If you palpate both carotid tubercles and arteries simultaneously, the carotid blood flow may be restricted. This will result in the initiation of the carotid reflex, an unpleasant and unwelcome experience for the patient. The carotid tubercle is also a useful landmark for the location of the stellate sympathetic ganglion, which as you may recall does not take kindly to deep palpation.
The posterior aspect and specific biomechanical relationships of the cervical spine will be covered in the next article. From reading this, you should have a greater appreciation of the structures that can and will mimic the patient's presenting complaint. You may also want to update your current examination procedures.