DOCSLIB.ORG

The Lower Extremity Exam for the Family Practitioner

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

Melinda A. Scott, D.O. THE LOWER EXTREMITY Orthopedic Associates of EXAM FOR THE FAMILY Dayton Board Certified in Primary Care PRACTITIONER Sports Medicine GOALS Identify landmarks necessary for exam of the lower extremity Review techniques for a quick but thorough exam Be familiar with normal findings and range of motion Review some special maneuvers and abnormal findings Review common diagnoses PRE-TEST QUESTIONS 20% 20% 20% 20% 20% If a patient has hip arthritis, where will he or she typically complain of pain? A. Buttock B. Low back C. Lateral hip D. Groin E. Posterior thigh 10 A. B. C. D. E. Countdown PRE-TEST QUESTIONS A positive straight leg raise test indicates 20% 20% 20% 20% 20% that the patient’s hip pain is from a A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive McMurray’s tests is indicative of 20% 20% 20% 20% 20% a possible A. ACL tear B. MCL tear C. Patellar dislocation D. Joint effusion E. Meniscus tear 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS Anterior drawer test on the knee is performed with the knee in 20% 20% 20% 20% 20% A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive squeeze test during an ankle 20% 20% 20% 20% 20% exam is indicative of A. Syndesmotic injury B. Anterior talofibular ligament strain C. Deep vein thrombosis D. Compartment syndrome E. Deltoid ligament injury 10 A. B. C. D. E. Countdown HIP EXAM Overview . Can be very complex area to exam . Long list of differential diagnoses to consider . Careful history narrows down the list considerably . Cannot examine the hip without examining the back . Physical exam is KEY HIP ANATOMY Bony Landmarks . ASIS . Sartorius . Greater trochanter . ITB . Gluteus medius . Pubic symphysis . Adductors . AIIS . Rectus femoris . Iliac crest . Abdominal oblique . Ischial tuberosity . Hamstrings . PSIS MUSCULATURE OF THE HIP HIP RANGE OF MOTION Flexion . 90 degrees with knee in extension . 120 degrees with knee in flexion Extension . 15 degrees Abduction . 45 degrees Adduction . 30 degrees Internal rotation . 40 degrees (with knee flexed) External rotation . 45 degrees (with knee flexed) HIP STRENGTH TESTING Hip flexors . Rectus femoris . Iliopsoas . Weakness with hip joint pathology (OA) . Test with hip flexed and knee extended HIP STRENGTH TESTING Hip extensors . Hamstrings . Weakness with isolated hamstring injury or radicular etiology HIP STRENGTH TESTING External rotators . Gluteus medius . Trendelenburg test . Have patient stand on affected leg. Unsupported hip will descend causing affected to hip to thrust outward . Weakness of gluteus medius HIP STRENGTH TESTING Adductors . Gracilis . Adductor longus . Weakness with isolated muscle strain HIP SPECIAL MANEUVERS Trendelenburg Straight leg raise (back) . With patient supine, flex the hip with the knee in full extension through 30-80 degrees . Positive test . Indicates radicular pain HIP DIFFERENTIAL DIAGNOSES Greater trochanteric bursitis . Pinpoint pain over the greater trochanter . Tight ITB . Sometimes pops or snaps as ITB crosses trochanter HIP DIFFERENTIAL DIAGNOSES Muscle strain/tendonitis . Hip flexor tendonitis . Hamstring/groin strain . Have pain over affected tendons . Weakness/pain with strength testing HIP DIFFERENTIAL DIAGNOSES Radicular pain . Radiating pain following a radicular pattern . Usually starts in posterior hip or low back . Hip motion does not typically reproduce pain . Positive SLR (in severe cases) . Cannot find position of comfort (severe cases) HIP DIFFERENTIAL DIAGNOSES Hip joint pathology . OSTEOARTHRITIS . Labral tears . AVN . Reproduced with internal/external rotation of the hip . Groin pain is hallmark for hip joint pain . Radiates to anterior/medial thigh, knee KNEE EXAM Overview . Rely a lot on palpation and observation of alignment/gait . Careful history . Lots of special maneuvers to help aid in diagnosis KNEE ANATOMY Bony landmarks . Femoral condyles . Fibular head . Patella . Tibial tuberosity . Tibial plateau KNEE ANATOMY Soft Tissue landmarks . MCL . LCL . Popliteal fossa . Patellar tendon . Medial/Lateral Joint line . Quad tendon . Bursa (prepatellar and pes anserine) . ITB INSPECTION AND PALPATION OF THE KNEE Deformity . Genu Varus . “Bow legged” . Medial compartment arthritis . Genu Valgus . “Knock- kneed” . Lateral compartment arthritis INSPECTION AND PALPATION OF THE KNEE Swelling . Effusion, soft tissue swelling or bursitis? . Prepatellar bursitis – fluid is extraarticular . Effusion is intraarticular INSPECTION AND PALPATION OF THE KNEE Crepitus . Peripatellar Popliteal fossa . Baker’s cyst KNEE RANGE OF MOTION Knee is a hinged joint Flexion-extension are primary movements Normal Flexion 0 to 130 degrees Normal Extension 0 to -15 degrees KNEE STRENGTH TESTING Quad . VMO weakness . Single leg squat . Straight leg raise (for integrity of patellar retinaculum) Hamstring KNEE SPECIAL MANEUVERS McMurray’s test . Patient supine or seated . One hand holding the foot, other hand across the joint . Rotate the leg externally, apply valgus stress and then slowly extend the knee . Pain or palpable click over medial joint line indicates medial meniscus tear . Repeat with leg internally rotated and with varus stress for lateral joint line KNEE SPECIAL MANEUVERS McMurray’s test KNEE SPECIAL MANEUVERS Patella testing . Patellar grind . Patient supine with leg relaxed . Push the patella distally into the patella groove and have patient tighten quad . Pain indicates patellofemoral pain . Patellar tracking . Single leg squat . Knee goes into valgus indicates VMO weakness KNEE INSTABILITY TESTS Anterior Drawer . Tests for laxity of the ACL . Performed with the patient supine . Knee flexed to 90 degrees, feet flat on table . Cup your hands around the joint with thumbs over medial and lateral joint line . Attempt to translate the tibia forward . Positive if tibia translates forward . Compare to other side KNEE INSTABILITY TESTS Lachman’s test - tests for laxity of the ACL . Generally accepted as a more sensitive test compared to Anterior drawer . Patient supine and knee in 20-30 degrees flexion . Stabilize thigh with one hand and try to translate tibia forward with other hand . Positive test if tibia translates forward . Compare to other side KNEE INSTABILITY TESTS Medial and lateral instability . Varus and valgus stress . Hold leg with one hand and apply varus or valgus stress to the knee . If the joint gaps, positive test for collateral ligament damage KNEE DIFFERENTIAL DIAGNOSIS Patellofemoral pain . Anterior/peripatellar pain, sitting to standing painful, stairs Ligamentous injury . Injury related typically . Chronic ACL tears common in older adult Meniscus tear . Joint line pain, mechanical symptoms Osteoarthritis . Joint line pain, stiffness Tendonitis . Patellar, quad and hamstring Bursitis . Prepatellar, pes anserine FOOT AND ANKLE Overall . Complex area . Common area to injury . Fractures common FOOT AND ANKLE ANATOMY AND PALPATION Bony landmarks . Medial and lateral malleolus . Distal tibia . Talus . Metatarsals . base of the 5th . Navicular . Toes FOOT AND ANKLE ANATOMY AND PALPATION Palpation/inspection . Soft tissue swelling/ecchymosis/erythema . Joint effusion (tibiotalar) . Ligaments (ATFL, CFL, deltoid) . Tendons (Achilles, posterior tibial, peroneal) . Plantar fascia . Pes planus/cavus deformities FOOT AND ANKLE RANGE OF MOTION Ankle Dorsiflexion /Plantarflexion . 20 degrees/45 degrees Foot Inversion/Eversion . 40 degrees/30 degrees Foot fAbduction/adduction . 10 degrees/20 degrees Toe flexion/extension FOOT AND ANKLE STRENGTH TESTING Dorsiflexors . Tibial anterior . Extensor Hallucis Longus . Extensor Digitorum Longus Plantar flexors . Peroneus Longus and Brevis . Gastrocnemius and Soleus . Flexor Hallucis Longus . Flexor Digitorum Longus . Tibialis Posterior FOOT AND ANKLE STRENGTH TESTING Everters of the Foot . Peroneus Longus and Brevis Inverters of the foot . Tibialis Anterior and Posterior FOOT AND ANKLE SPECIAL MANEUVERS Drawer test – tests for instability of the ankle . Stabilize tibia with one hand and cup the calcaneus with the other hand . With foot slightly plantarflexed, slide the foot toward you . Positive test if talus translates anteriorly . Indicates tear of ATFL FOOT AND ANKLE SPECIAL MANEUVERS Squeeze test . Tests for disruption of the syndesmosis of the ankle . Compress/squeeze the proximal calf with one or two hands . Positive if causes pain at the distal syndesmosis . Causes widening of the syndesmosis distally . Indicates syndesmotic injury (anterior tibiofibular ligament) FOOT AND ANKLE SPECIAL MANEUVERS Thompson Test . Tests for rupture of the Achilles tendon . Place patient prone with foot and ankle off the edge of the table . Gently squeeze the calf which should cause the foot to plantarflex . Positive if foot does not plantarflex FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Medial/lateral ankle sprains . Lateral most common ligament injury . High ankle sprains have sprain of syndesmosis Achilles tendinosis/rupture . Rupture requires urgent orthopedic referral FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Plantar fasciitis . Pain over plantar surface of calcaneus . Pes planus deformity typically Tendonitis (peroneal, posterior tibial) FOOT AND ANKLE DIFFERENTIAL DIAGNOSIS Fractures . Base of the 5th metatarsal (Jones fracture) . Distal fibula . Stress fractures
Recommended publications
  • Effusion =S Fluid in Pleural Space (Outside of Lung) Fremitus - Pathophysiology • Fremitus: – Increased W/Consolidation (E.G

    Effusion =S Fluid in Pleural Space (Outside of Lung) Fremitus - Pathophysiology • Fremitus: – Increased W/Consolidation (E.G

    General Part Head and Neck Cardiovascular Abdomen Lung Muscles Lung Exam • Includes Vital Signs & Cardiac Exam • 4 Elements (cardiac & abdominal too) – Observation – Palpation – Percussion – Auscultation Pulmonary Review of Systems • All organ systems have an ROS • Questions to uncover problems in area • Need to know right questions & what the responses might mean! Exposure Is Key – You Cant Examine What You Can’t See! Anatomy Of The Spine Cervical: 7 Vertebrae Thoracic: 12 Vertebrae Lumbar: 5 Vertebrae Sacrum: 5 Fused Vertebrae Note gentle curve ea segment Hammer & Nails icon indicates A Slide Describing Skills You Should Perform In Lab Spine Exam As Relates to the Thorax • W/patient standing, observe: – shape of spine. – Stand behind patient, bend @ waist – w/Scoliosis (curvature) one shoulder appears “higher” Pathologic Changes In Shape Of Spine – Can Affect Lung Function Scoliosis (curved to one side) Thoracic Kyphosis (bent forward) Observation • ? Ambulates w/out breathing difficulty? • Readily audible noises (e.g. wheezing)? • Appearance →? sitting up, leaning forward, inability to speak, pursed lips → significant compromise • ? Use of accessory muscles of neck (sternocleidomastoids, scalenes), inter-costals → significant compromise / Make Note of Chest Shape: Changes Can Give Insight into underlying Pathology Barrel Chested (hyperinflation secondary to emphysema) Examine Nails/Fingers: Sometimes Provides Clues to Pulmonary Disorders Cyanosis Nicotine Staining Clubbing Assorted other hand and arm abnormalities: Shape, color, deformity
  • Frequently Asked Questions

    Frequently Asked Questions

    Frequently Asked Questions What are the requirements for license renewal? Licenses Expire Contact Hours Required Each three-year registration renewal period in the licensee’s month of birth. 36 contact hours How do I complete this course and receive my certificate of completion? On-Line Submission: Go to PT.EliteCME.com and follow the prompts.You will be able to print your certificate immediately upon completion of the course. Fax Submission: Fax to (386) 673-3563, be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates e-mailed to the e-mail address provided.* Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL 32175. All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid e-mail address is the quickest and most efficient way to receive your certificates when submitting via fax, e-mail or mail. Submissions without a valid e-mail address will be mailed to the address provided at registration. How much will it cost? Cost of Courses Course Title Contact Hours Price Acute Injury and Pain: A Strategy, Management and Rehabilitation Discussion for Physical 3 $18.00 Therapists An Overview of Oncology Rehabilitation 4 $24.00 Common Injuries and Therapy Management for Runners 4 $24.00 Lifestyle and Therapy Approaches to Osteoporosis 3 $18.00 Reducing and Eliminating Workplace Injuries Through Ergonomics 2 $12.00 Stroke: Risk Factor Assessment, Rehabilitation Protocols and Best Practices for Prevention 2 $12.00 BEST VALUE 18-HOUR COURSE BOOK PACKAGE SAVE $11.00 18 $97.00 Are you a department approved provider? Elite Professional Education, LLC is recognized by The New York State Education Department’s Board of Physical Therapy as an approved provider of physical therapy and physical therapist assistant continuing education.
  • Discussion Concerning Deltoid Ligament and Antero-Medial Capsule Repair in the Surgical Management of Supination External Rotati

    Discussion Concerning Deltoid Ligament and Antero-Medial Capsule Repair in the Surgical Management of Supination External Rotati

    ISSN: 2643-4016 Wei et al. Int Arch Orthop Surg 2017, 1:001 Volume 1 | Issue 1 Open Access International Archives of Orthopaedic Surgery ORIGINAL ARTICLE Discussion Concerning Deltoid Ligament and Antero-Medial Cap- sule Repair in the Surgical Management of Supination External Rotation Ankle Fractures Wei REN1,3, Masumi MARUO HOLLEDGE1, Yong Cheng HU2,3 and Jike LU1* 1Department of Orthopedic Surgery, United Family Hospital, Beijing, China Check for 2Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China updates 3Tianjin Medical University, Tianjin, China *Corresponding author: Jike LU, Department of Orthopedic Surgery, United Family Hospital, 2 Jiangtai Lu, Chaoyang District, Beijing, China, Tel: +4008-9191-91, E-mail: [email protected] the Lauge-Hansen classification is frequently utilized. Abstract In the classification, Supination-External Rotation (SER) Objective: To evaluate the importance of ankle deltoid liga- injuries are the most common occurrences. In a clinical ment and anteromedial capsule repair in Lauge-Hansen Su- pination-External Rotation Stage IV (SER IV) ankle fractures. setting, SER stage IV (SER IV) can be seen as a fracture of the lateral malleolus (Weber B fibular fractures) on Methods: A total of 15 patients with SER IV ankle fractures radiographs, when there is no medial malleolus frac- without medial malleolus fractures, were studied. All patients were treated with lateral malleolus Open Reduction Internal ture. However, the classification indicates that SER IV Fixation (ORIF) and transsydesmotic screws with the deltoid injuries include the syndesmotic ligament rupture and ligament, as well as anteromedial capsule repair. The Lower the deltoid ligament injuries (bimalleolar equivalent). Extremity Function Scale (LEFS), Foot and Ankle Disabili- Obviously, SER IV injuries are unstable ankle fractures.
  • A Comparative Study on Immediate Effects of Traction Straight Leg And

    A Comparative Study on Immediate Effects of Traction Straight Leg And

    International Jour nal of Applie d Rese arc h 2019; 5(4): 274-278 ISSN Print: 2394-7500 ISSN Online: 2394-5869 A comparative study on immediate effects of traction Impact Factor: 5.2 IJAR 2019; 5(4): 274-278 straight leg and bent leg raise on hamstring muscle www.allresearchjournal.com Received: 07-02-2019 flexibility in normal individuals Accepted: 09-03-2019 Pooja D Kapadia Intern at Late Shree Fakirbhai Pooja D Kapadia and Dr. Virendra K Meshram Pansare Education Foundation’s College Of Abstract Physiotherapy, Nigdi, Pune, Background: Muscular flexibility is an important aspect of normal human function. Limited flexibility Maharashtra, India has been shown to predispose a person to several musculoskeletal overuse injuries and significantly affect a person’s level of function. The objective of our study was to find out the effect of mulligan Dr. Virendra K Meshram Traction Straight Leg Raise (TSLR) on hamstring flexibility, to find out the effect of Mulligan bent Leg Associate Professor, Raise (BLR) on hamstring flexibility & Comparison of Mulligan TSLR & Mulligan BLR on hamstring Department of Cardiovascular and Respiratory flexibility in normal individuals. Physiotherapy, Late Shree Method: For the present study, a total of 124 physiotherapy students were screened; of which 50 adults Fakirbhai Pansare education with hamstring muscle tightness were recruited and randomly divided into two groups: Group A- given Foundation’s College Of Mulligan Traction Straight Leg Raise and Group B- given Mulligan Bent Leg Raise. Hamstring Physiotherapy, Nigdi, Pune, flexibility was measured before and after the application of each stretching technique with the use of sit Maharashtra, India and reach test.
  • Ankle Ligament Injuries

    Ankle Ligament Injuries

    ARTIGO DE REVISÃO Ankle ligament injuries Per A.F.H. Renström, M.D., Ph.D.1 and Scott A. Lynch, M.D.2 ABSTRACT ing and/or taping can alleviate instability problems in most patients. For cases of chronic instability that are refractory Acute ankle ligament sprains are common injuries. The to bracing and external support, surgical treatment can be majority of these occur during athletic participation in the explored. If the chronic instability is associated with subta- 15 to 35 year age range. Despite the frequency of the injury, lar instability that is refractory to conservative measures and diagnostic and treatment protocols have varied greatly. bracing as outlined above, surgical treatment must address Lateral ligament complex injuries are by far the most com- the subtalar joint as well. mon of the ankle sprains. Lateral ligament injuries typically Subtalar ligament injury and instability are probably more occur during plantar flexion and inversion, which is the po- common than appreciated. Definition and diagnosis of this sition of maximum stress on the anterotalofibular liagment entity are difficult, however. Fortunately, it appears that in (ATFL). For this reason, the ATFL is the most commonly the majority of the acute injuries healing occurs with the torn ligament during an inversion injury. In more severe in- same functional rehabilitation program as that for lateral ankle version injuries the calcaneofibular (CFL), posterotalofibu- ligament sprains. lar (PTFL) and subtalar ligament can also be injured. For chronic subtalar instability an intial attempt at func- Most acute lateral ankle ligament injuries recover quickly tional rehabilitation with ankle proprioceptive training and with nonoperative management.
  • Meniscus Injury

    Meniscus Injury

    Introduction Role of menisci • Medial meniscus lesions are more common than 01 lateral meniscus because it is attached to the improving articular capsule that make it less mobile thus it cannot congruency and increasing easily to accommodate the abnormal stresses. the stability of the knee • In increasing age – gradual degeneration and change in the material properties of the menisci Meniscus controlling the complex thus splits and tears are more likely that usually associated with osteoarthritic articular damage or rolling and gliding actions of chondrocalcinosis. Injury the joint • In younger people - meniscal tears are usually the result of trauma, with a specific injury identified in distributing load during the history. movement Tear of Meniscus Pathology Pathology • Usually, meniscus more likely to tear along its Vertical tear Horizontal tear length than across its width because the Bucket-handle tear usually ‘degenerative’ or due to repetitive minor trauma meniscus consists mainly of circumferential the separated fragment remains attached front complex with the tear pattern lying in many collagen fibres held by a few radial strands. and back planes The torn portion can sometimes displace towards may be displaced or likely to displace • The meniscus is usually torn by a twisting the centre of the joint and becomes jammed If the loose piece of meniscus can be displaced, it between femur and tibia acts as a mechanical irritant, giving rise to force with the knee bent and taking weight. This causes a block to movement with the patient recurrent synovial effusion and mechanical describing a ‘locked knee’ symptoms • In middle life, tears can occur with relatively posterior or anterior horn tears Some are associated with meniscal cysts little force when fibrotic change has the very back or front of the meniscus is It is also suggested that synovial cells infiltrate into the vascular area between meniscus and restricted mobility of the meniscus.
  • Comparison of the Thesslay Test and Mcmurray Test: a Systematic

    Comparison of the Thesslay Test and Mcmurray Test: a Systematic

    py & Ph ra ys e i th c Alexanders et al.,Physiother Rehabil 2016, 1:1 a io l s R y e Journal of DOI: 10.4172/2573-0312.1000104 h h a P b f i o l i l t a ISSN:a 2573-0312 t n i r o u n o J Physiotherapy & Physical Rehabilitation Research Article Open Access Comparison of the Thesslay Test and McMurray Test: A Systematic Review of Comparative Diagnostic Studies Jenny Alexanders1*, Anna Anderson2, Sarah Henderson1 and Ulf Clausen3 1Sport, Health and Sciences Department, The University of Hull, Washburn Building, Cottingham Road, Hull, United Kingdom 2Leeds Teaching Hospitals, Beckett Street, Leeds, LS9 7TF, United Kingdom 3Dr Hill and Partners, Beverly Health Practice, Manor Road, Hull, HU17 7BZ, United Kingdom Abstract Background: The Thessaly test is a relatively recently developed meniscal test; therefore research compared to other meniscal tests is somewhat limited. In addition, a systematic review comparing the Thessaly’s test with a long standing test such as the McMurray test has not been previously conducted. Objective: To systematically identify and appraise all empirical studies comparing the diagnostic accuracy of the Thessaly test and McMurray test. Procedure: Eligible studies were identified through a rigorous search of ScienceDirect, CINAHL Plus, Pubmed, PEDro, EMBASE and Cochrane Library from January 2004 until August 2014. Full English reports of studies investigating the accuracy of the Thessaly test and McMurray test. Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) scores were completed on each selected article. Results: The Thessaly test reported to have higher diagnostic accuracy values (61-96%) compared to the McMurray test (56-84%).
  • Physical Esxam

    Physical Esxam

    Pearls in the Musculoskeletal Exam Frank Caruso MPS, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019 Examination Key Points • Area that needs to be examined, gown your patients - well exposed • Understand normal functional anatomy • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Special Tests General Exam Musculoskeletal Overview Physical Exam Preview Watch Your Patients Walk!! Inspection • Posture – Erectness – Symmetry – Alignment • Skin and subcutaneous tissues – Swelling – Redness – Masses Inspection • Extremities – Size – Deformities – Enlargement – Alignment – Contour – Symmetry Inspection • Muscles – Bilateral symmetry – Hypertrophy – Atrophy – Fasciculations – Spasms Palpation • Palpate bones, joints, and surrounding muscles for the following: – Heat – Tenderness – Swelling – Fluctuation – Crepitus – Resistance to pressure – Muscle tone Muscles • Size and strength affected by the following: – Genetics – Exercise – Nutrition • Muscles move joints through range of motion (ROM). Muscle Strength • Compare bilateral muscles – Strength – Symmetry – Equality – Resistance End Feel Think About It!! • The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be elbow extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel • Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee extension and metacarpophalangeal joint extension. Abnormal End Feel • Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced.
  • Evaluation and Management of Sports Injuries in Children

    Evaluation and Management of Sports Injuries in Children

    2019 Frontiers in Pediatrics Sports Medicine Mini-Symposium Presented by MUSC Health Sports Medicine Sports Medicine Panel of Experts Michael J. Barr, PT, DPT, MSR Sports Medicine Manager MUSC Health Sports Medicine Alec DeCastro, MD Assistant Professor CAQ Sports Medicine Director, MUSC/Trident Family Medicine Residency MUSC Health Sports Medicine MUSC Department of Family Medicine Harris S. Slone, MD Associate Professor Orthopaedic Surgery and Sports Medicine MUSC Health Sports Medicine MUSC Department of Orthopaedics Sports Medicine Breakout Group Leaders Aaron Brown, ATC Athletic Trainer MUSC Health Sports Medicine Amelia Brown, MS, ATC Athletic Trainer MUSC Health Sports Medicine Brittney Lang, MS, ATC Athletic Trainer MUSC Health Sports Medicine Bobby Weisenberger, MS, ATC, PES Athletic Trainer MUSC Health Sports Medicine Sports Medicine Schedule Approximate Timeline: 2:00: Introduction – Michael Barr, PT, DPT, MSR – Sports Medicine Manager 2:05: Ankle Case Report – Harris Slone, MD 2:20: Knee Case Report – Harris Slone, MD 2:35: Shoulder Instability Case Report – Michael Barr, PT, DPT, MSR 2:50: Back Case Report – Alec DeCastro, MD 3:05: High BP Case Report – Alec DeCastro, MD 3:20: Hands On Practice of Exam Techniques – All + Athletic Trainers 3:50: Question/Answer Open Forum – All 4:00: End Sports Medicine Disclosers No relevant financial disclosers Sports Medicine Learning Objectives Learning Objectives: 1. Describe mechanisms of injury and clinical presentation for common pediatric sports related injuries of the ankle, knee, back and shoulder. 2. Demonstrate examination techniques to support the diagnosis of common pediatric sports related injuries of the ankle, knee, back and shoulder 3. Determine what imaging studies should be ordered and when to refer to a sports med/orthopaedic surgeon or to physical therapy 4.
  • Examination of the Knee

    Examination of the Knee

    Examination of the Knee The Examination For every joint of the lower extremity always begin with the patient in standing IN STANDING INSPECTION 1. Cutaneous Structures: Look for Erythema, scarring, bruising, and swelling in the following areas: a. Peripatellar grooves b. Suprapatellar bursa c. Prepatellar bursa d. Infrapatellar tendon e. Anserine bursa f. Popliteal fossa 2. Muscle & Soft Tissue: a. Quadriceps atrophy b. Hamstring atrophy c. Calf atrophy 3. Bones & Alignment: a. Patella position (Alta, Baha, Winking, Frog eyed), b. Varus or Valgus alignment c. Flexion contracture or Genu recurvatum RANGE OF MOTION - ACTIVE Standing is the best opportunity to assess active range of motion of the knee. 1. Ask the patient to squat into a deep knee bend. Both knees should bend symmetrically. 2. Ask the patient to then stand and extend the knee fully – lock the knee. The knee should straighten to 0 degrees of extension. Some people have increased extension referred to as genu recurvatum. GAIT 1. Look for a short stance phase on the affected limb and an awkward gait if a concomitant leg length discrepancy 2. Look for turning on block 3. Screening 1. Walk on the toes 2. Walk on the heels 3. Squat down – Active Range of Motion testing SPECIAL TESTS 1. Leg Length Discrepancy a. Look at patients back for evidence of a functional scoliosis b. Place your hands on the patients Iliac crests looking for inequality which may mean a leg length discrepancy IN SITTING NEUROLOGIC EXAMINATION 1. Test the reflexes a. L4 – Quadriceps reflex VASCULAR EXAMINATION 1. Feel for the posterior tibial artery SUPINE POSITION INSPECTION 1.
  • SIMMONDS TEST:  Patient Is Prone  Doctor Flexes the Patients Knee to 90 Degrees  Doctor Squeezes the Patient’S Calf

    SIMMONDS TEST:  Patient Is Prone  Doctor Flexes the Patients Knee to 90 Degrees  Doctor Squeezes the Patient’S Calf

    Clinical Orthopedic Testing Review SIMMONDS TEST: Patient is prone Doctor flexes the patients knee to 90 degrees Doctor squeezes the patient’s calf. Classical response: Failure of ankle plantarflexion Classical Importance= torn Achilles tendon Test is done bilaterally ACHILLES TAP: Patient is prone Doctor flexes the patient’s knee to 90 degree Doctor dorsiflexes the ankle and then strikes the Achilles tendon with a percussion hammer Classical response: Plantar response Classical Importance= Intact Achilles tendon Test is done bilaterally FOOT DRAWER TEST: Patient is supine with their ankles off the edge of the examination table Doctor grasps the heel of the ankle being tested with one hand and the tibia just above the ankle with the other. Doctor applies and anterior to posterior and then a posterior to anterior sheer force. Classical response: Anterior or posterior translation of the ankle Classical Importance= Anterior talofibular or posterior talofibular ligament laxity. Test is done bilaterally LATERAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other. Doctor rotates the foot into inversion Classical response: Excessive inversion Classical Importance= Anterior talofibular ligament sprain Test is done bilaterally MEDIAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other Doctor rotates the foot into eversion Classical response: Excessive eversion Classical Importance= Deltoid ligament sprain Test is done bilaterally 1 Clinical Orthopedic Testing Review KLEIGER’S TEST: Patient is seated with the legs and feet dangling off the edge of the examination table. Doctor grasps the patient’s foot while stabilizing the tibia with the other hand Doctor pulls the ankle laterally.
  • The Ligament Anatomy of the Deltoid Complex of the Ankle: a Qualitative and Quantitative Anatomical Study

    The Ligament Anatomy of the Deltoid Complex of the Ankle: a Qualitative and Quantitative Anatomical Study

    e62(1) COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED The Ligament Anatomy of the Deltoid Complex of the Ankle: A Qualitative and Quantitative Anatomical Study Kevin J. Campbell, BS, Max P. Michalski, MSc, Katharine J. Wilson, MSc, Mary T. Goldsmith, MS, Coen A. Wijdicks, PhD, Robert F. LaPrade, PhD, MD, and Thomas O. Clanton, MD Investigation performed at the Department of Biomedical Engineering, Steadman Philippon Research Institute, and the Steadman Clinic, Vail, Colorado Background: The deltoid ligament has both superficial and deep layers and consists of up to six ligamentous bands. The prevalence of the individual bands is variable, and no consensus as to which bands are constant or variable exists. Although other studies have looked at the variance in the deltoid anatomy, none have quantified the distance to relevant osseous landmarks. Methods: The deltoid ligaments from fourteen non-paired, fresh-frozen cadaveric specimens were isolated and the ligamentous bands were identified. The lengths, footprint areas, orientations, and distances from relevant osseous landmarks were measured with a three-dimensional coordinate measurement device. Results: In all specimens, the tibionavicular, tibiospring, and deep posterior tibiotalar ligaments were identified. Three additional bands were variable in our specimen cohort: the tibiocalcaneal, superficial posterior tibiotalar, and deep anterior tibiotalar ligaments. The deep posterior tibiotalar ligament was the largest band of the deltoid ligament. The origins from the distal center of the intercollicular groove were 16.1 mm (95% confidence interval, 14.7 to 17.5 mm) for the tibionavicular ligament, 13.1 mm (95% confidence interval, 11.1 to 15.1 mm) for the tibiospring ligament, and 7.6 mm (95% confidence interval, 6.7 to 8.5 mm) for the deep posterior tibiotalar ligament.