Page 102 Guide to Pain Management in Low-Resource Settings

90 Richard Fisher

muscles are weak or if there is a painful hip problem been embarrassed by a slapping sound his foot makes
the pelvis will fall and the patient will lean the upper walking down the halls at school. His right foot feels tin-
body in the opposite direction. gly at times, but he has noticed no problems with bowel
or bladder control, and his left leg seems fi ne. He does
Knee: take anti-infl ammatory medication when his back hurts

The knee can be examined with the patient sitting a lot, but usually not every day.
or supine. You notice he gets up slowly to move to the exam
1) Palpate the surface location of the patella, the pa- table but can stand up straight. His spine alignment
tellar tendon, the head of the fi bula, and the medial and looks satisfactory, but he has limited range of motion,
lateral joint lines. with only a few degrees of fl exion and lateral bending to
2) Check knee range of motion—fl exion/extension. 20°. Th ere is mild tenderness to palpation over the lum-
3) Test the stability of the medial and lateral collat- bar muscles only.
eral ligaments with the knee in full extension and fl exed Sensation is intact to sharp/dull discrimination,
to 30°. except on the lateral right calf and the dorsum of the
4) Test the integrity of the anterior and posterior right foot. You ask him to walk on his heels and toes. He
cruciate ligaments with the knee in 30 and 90° of fl ex- does this with no diffi culty, except he cannot walk on his
ion. right heel while keeping his toes off of the ground. Big toe
5) Evaluate meniscus integrity. extension is weak to manual testing. Deep tendon refl ex-
6) Check for pain with compression across the knee es at the knee and ankle are normal and symmetrical.
joint while fl exing, extending, and rotating the joint. Th e straight leg raising test (sciatic nerve stretch test) is
7) Check for tenderness along the meniscus inser- not painful on the left to 80°, but on the right it produces
tion at the joint line. pain into the calf at 40°.
8) Check for an impediment to full extension.
9) Check the patella refl ex. Where do you suspect his primary problem lies?
• Muscles of the calf?
Ankle and foot: • Sciatic nerve posterior to the hip joint?

1) Palpate the surface location of: • Th e intervertebral disk between the last lumbar
a. the medial and lateral malleoli and the collat- and the fi rst sacral vertebral bodies?
eral ligaments. • Knee and ankle joints?
b. the insertion of the plantar fascia • Th e intervertebral disk between L4 and L5 verte-
c. the major tendons (Achilles, anterior/poste- bral bodies?
rior tibial, peroneal, and toe extensors)
2) Check the range of motion of the ankle, midfoot, How do you reach a diagnosis?
and hindfoot joints. Potentially abnormalities of the calf muscles (especial-
3) Evaluate the Achilles refl ex. ly those in the anterior compartment) or of the sciatic
nerve in the thigh could produce some of these symp-
Clinical case story 2 (spine) toms. However, the patient tells you that the pain fi rst
began in his back and then spread to the posterior thigh
A patient in the clinic tells you he has been bicycling and calf. Also, the positive straight leg raising test indi-
about 12 miles to and from school each day for the past cates irritation at the nerve root level as it is stretched
year. He says that last month as the weather was becom- over a protruding disk.
ing cooler he noticed tightness in his lumbar muscles Th e patient’s neurological symptoms and signs
and had diffi culty standing up straight when arrived at suggest a pattern of function loss that you can trace. His
school. For a while only his back was aff ected, but re- sensory loss involves the lateral calf and dorsum of the
cently he has developed pain in the right posterior thigh foot—look at the dermatome map—L5 root. Similarly
and calf, which is increased by sitting in class, bending the slapping foot and toe extensor weakness involve an-
forward, or sneezing. terior compartment muscles—this could result from an-
Last week he tripped several times when his right terior compartment compression, peroneal nerve injury,
toes caught on a carpet edge, and he says that he has or the L5 root. Refl exes at the knee (L4) and ankle (S1)