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 A brief presentation of imaging techniques of interest to the physiatrist must necessarily be selective. Because the diagnosis and initial treatment of fractures are primarily the responsibility of the orthopedic surgeon, with the rehabilitation professional typically involved only later in the course, a full discussion of fractures is not presented in this chapter. Only those fractures that bring patients under the long-term care of the physiatrist are included (e.g., vertebral fractures with the potential to damage the spinal cord). Similarly, tumors and infectious processes are de-emphasized. Rather, emphasis is placed on imaging degenerative musculoskeletal processes, spine and head trauma, stroke, and degenerative central nervous system (CNS) diseases commonly seen by the physiatrist. We will also cover imaging in sport medicine as this is a rapidly changing area in radiology and review the current applications of diagnostic ultrasound in the evaluation of musculoskeletal disorders.

In the past two decades, computed tomography (CT) and magnetic resonance imaging (MRI) have become the most sophisticated imaging modalities for evaluating the musculoskeletal system and the CNS. Therefore, this chapter focuses mainly on the recent applications of CT and MRI in the imaging of musculoskeletal and neural pathology of interest to the physiatrist. In the final section, we will introduce some relatively new imaging technologies of interest to the physiatrist, including advanced MRI methods and ultrasound imaging (USI).

The role of plain film examinations in the assessment of abnormalities of specific joint disorders is well established in the medical literature. A brief review of the most commonly performed radiographic examinations of the extremities will be done when addressing the specific subject. 


The hallmark of medicine has always been the physical examination. Perhaps more than the actual diagnosis, the process by which the physician arrives at his or her conclusion has defined the "art" of medicine. Much has been written about the techniques by which this art is performed, and much more will continue to be written. Each generation will take from the past and apply these techniques to the future of medicine.

The physical examination is an extension of the history and extends the doctor-patient relationship initially established during the history. The skill with which the examination is performed instills a sense of confidence in the patient that the examiner knows what he or she is doing. This confidence in the physician has a positive outcome on the patient's ability to recover. Finally, the physical examination serves to narrow the list of diagnostic possibilities.

In a specialty like physiatry, in which the whole person is evaluated in terms of function, there is no adjunct more important than the physical examination. The examination provides the foundation to formulate a plan to improve a person's function. Importantly, though, in looking at function, each piece must be applied to the whole person. The examination of one joint must be applied to the whole picture of the patient, and an understanding of functional biomechanics will enable the physician to include in the physical examination other structures that may indirectly contribute to the impairment.

The focus on function and application to the whole person in physiatry can be best seen in understanding the concept of the kinetic chain. No one joint, bone, or muscle acts alone in the body. An ankle sprain can lead to low-back pain. Lowback pain can affect the serve of a tennis professional. Lateral epicondylitis can alter shoulder mechanics and lead to rotator cuff impingement. It is because of these relationships that the physiatrist must perform a thorough examination. It is this comprehensive manner that sets apart the physiatric approach from others. A thorough knowledge of the neuromuscular system and an understanding of functional biomechanics will narrow the focus of the examination so it can be done in a time-efficient manner. The relationship between the different joints and regions must be understood. In addition, a complete understanding of the muscles and their innervation is required.

An understanding of the muscle kinesiology and biomechanics is very important in the physical examination. Each muscle functions across one or more joints to provide motion or stabilization. One example would be the hamstrings. When the foot is planted, the hamstrings act in their primary function as powerful hip extensors. However, with the foot off the ground, they can become knee flexors. With a patient prone and the knee bent at 90 degrees, the gluteus maximus acts as the primary extensor because of the shortened hamstrings. Place the knee in full extension, and the hamstrings will once again act as hip extensors. We will look further into these types of relationships in the physical examination.

In today's medicine, there exists a tremendous amount of information to digest. The number of articles indexed in MEDLINE has grown in size from 1,098,000 citations in 1970 to 11,761,000 in 2000. The modern physician must have an understanding of the body down to a microcellular level. In addition, access to modern tests like magnetic resonance imaging (MRI) is achieved by a greater number of patients. Any test has its limitations, and in the example of the MRI, these can be multiple false-positive findings (1). The MRI should be used to confirm not make a diagnosis. Many physician referrals are generated from a radiologist's interpretation of a study, often without physical examination findings consistent with the results of the study. It is at this point that the well-trained physiatrist can be the link using evidence-based medicine as it applies to diagnosis, history, and physical examination.

Whole texts are dedicated to the physical exam. Due to the limits of one chapter, this will be an introduction to the physical examination and kinesiology of the cervical spine, shoulder, lumbar spine, and knee. That said, the reader should be able to approach any joint in the manner laid out here to aid in his or her diagnosis. Examination of any joint should be performed in a systematic approach. As the examination begins, the clinician should make sure that the area to be examined is properly exposed for evaluation and the patient appropriately draped. We have focused on the major joints seen in our practice—the cervical and lumbar regions of the spine, the shoulder, and the knee. Other joints will be addressed in chapters in this text. We will now address the physical examination, and the kinesiology of the muscles and joints will be explained. For reference, the dermatomes, myotomes, and sclerotomes are illustrated in Chapter 21.

It is the task of the physiatrist to perform a thorough physical examination to confirm his or her diagnosis derived from the history and additional information. It even is more important today, because of the additional tests modern technology has advanced, to understand physical examination maneuvers and their diagnostic relevance.

Joseph H. Feinberg and Peter J. Moley

Source: Physical Medicine and Rehabilitation - Principles and Practice

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