DOCSLIB.ORG

Best Tests for Differential Diagnosis What Are the Metrics of Diagnosis?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Best Tests for Differential Diagnosis What Are the Metrics of Diagnosis? 9/6/2018 Best Tests for Differential Diagnosis What are the Metrics Chad Cook PhD, PT, MBA, FAAOMPT of Diagnosis? Professor and Program Director Duke University Duke Clinical Research Institute For Diagnosis, There are Analytic Diagnostic Test Metrics Metrics • Diagnostic accuracy • Reliability • Diagnostic accuracy relates to the ability of • Sensitivity a test to discriminate between the target condition and another competing condition. • Specificity • Positive and Negative Predictive Value • Positive and Negative Likelihood Ratios Does Reliability Matter? Sensitivity and Specificity No worries, The you will Sensitivity: Percentage of people who test positive for a condition • be fine is fatal specific disease among a group of people who have the disease • Specificity: Percentage of people who test negative for a specific disease among a group of people who do not have the disease Kappa Intraclass Correlation www.zillowblog.com Coefficient 5 1 9/6/2018 Sensitivity Example Specificity Example • 50 patients with arm pain associated • 50 patients with no arm pain with cervical radiculopathy associated with a cervical strain • Test was positive in 40 of the 50 • Test was positive in 5 of the 50 cases cases • Sensitivity = 40/50 or 80% • Specificity = 45/50 or 90% • Correct 80% of the time in cases • Correct 90% of the time in cases that were cervical radiculopathy that were NOT cervical radiculopathy http://www.triggerpointbook.com/infrasp2.gif http://www.triggerpointbook.com/infrasp2.gif Likelihood Ratios • A high LR+ influences post-test probability with a positive finding • A value of >1 rules in a diagnosis • A low LR- influences post-test probability with a negative finding • A value closer to 0 is best and rules out Bossuyt P, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Family Practice. 2004;21:4-10. Clinical Utility Fagen’s Nomogram (LR+) • Cervical • The ability of the metrics to influence post-test probability Radiculopathy (either in ruling out the condition or ruling it in) • Pretest • Or just improving your likelihood of being correct prob=18% • Spurling’s LR+=4.8 • Post test prob of a positive finding= 52% 2 9/6/2018 Fagen’s Nomogram (LR-) Confidence Intervals? • Cervical • Wainner’s CPR for Radiculopathy CTS • Pretest prob=18% • 34% pre-test prob • ULTT (LR- = 0.14) • <4/5 of the tests • Post test prob of a • LR+ = 4.6 (95%CI negative finding = 2.5, 8.7) 2.98% • Post-test probability = 70% (56.3%, 81.7%) Tests Should be Used in Proper Examination in Series Order R/O R/I • Some tests should High Sensitivity High Specificity typically be used early Low LR- High LR+ • E.g., SLR, ULTT, Hawkins Kennedy, • Some late in the examination R/O R/I • Spurlings, Hoffmann’s test, Intake Observation Movement Exam MMT/Endurance Well leg Raise Patient History Screening Palpation/Exam Confirmatory Tests OTHERWISE YOUR RESULTS WILL BE BIASED 15 Fagen’s Nomogram Example One-Screening (LR-) • Hoffmann’s test (sign) for • Cervical myelopathy Myelopathy • Sensitivity = 50% and a negative • Pretest prob=5% likelihood ratio of 0.74 • Hoffmann’s LR- • Negative finding is of interest =0.74 • 50% will have a negative, but will • Post test prob of have the disease a negative finding= 4% 3 9/6/2018 Fagen’s Nomogram (LR+) Example Two-Confirming • Straight leg raise • Lumbar • Sensitivity is about 90% Radiculopathy • Specificity is about 15% and • Pretest positive likelihood ratio is 1.24 prob=25% • This means that it is positive in • SLR LR+=1.24 those that have radiculopathy • Post test prob of and those that don’t have it a negative finding= 27% Calculations Influencing Decision Making • Positive Likelihood Ratio= (sensitivity)/(1-specificity) • Negative Likelihood Ratio= (1-sensitivity)/(specificity) Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. 22 What if You Don’t Care to Follow This? Diagnostic Clinical Utility • You run the risk of • To what extent diagnostic testing “ruling out” improves health outcomes relative conditions that are to the current best alternative, actually present which could be some other form • You run the risk of of testing, or not testing at all. “confirming” conditions that are not really there Bossuyt et al. Beyond diagnostic accuracy: the clinical utility of diagnostic tests. Clin Chem. 2012 Jun 33 It increases the risks of an error [Epub ahead of print] 24 4 9/6/2018 Screening • (Technically) Screening is performed to detect the presence of a specific disease. The individual or Red Flags, Triage, and group of individuals (as in mass screenings) does not Screening present any symptoms of the disease. • The correct use involves screening of healthy Chad Cook PT, PhD, MBA, FAAOMPT subjects Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University Natural History of Disease Spot Diagnosis or Triage Screening • Differential assessment for red flags in individual Latency Period *Detectable patients by a clinician using special tests or Sojourn Time* Preclinical standardized examinations in order to identify Period individuals needing special intervention. Biological Detectable Symptoms Diagnosed Becomes Onset by testing begin w/ disease disabling Dx Test Primary Secondary Tertiary Sizer P, Brismee JM, Cook C. Medical screening for red flags in the diagnosis and management of Prevention Prevention Prevention 27 musculoskeletal spine pain. Pain Pract. 2007 (in press). Clinical Triage Examples Differences? Screening Sport Diagnosis or Triage • Canadian C-Spine Rules are used to determine who doesn’t need an x-ray ( sensitivity-99%) X-ray is used to diagnose fracture ( specificity) • Ottawa Ankle Rules are used to determine who doesn’t need an x-ray ( sensitivity) X-ray is used to diagnose fracture ( specificity) Healthy Population/Population based Patient Population www-chaos.umd.edu http://www.providencecare.ca/objects/rte/Image/images/patients-main-pg-final.jpg 5 9/6/2018 Triage: Sinister Disorders (Red What is a Red Flag? Flags) • Signs and Symptoms found in the patient history and clinical • Rare, but occasionally examination that may tie a disorder to a serious pathology. present (<1% of cases) • Sometimes is identified as a finding that is reflective of a • Most guidelines suggest delayed or poor outcome. that “when something • We call this a prognostic red flag. seems wrong, it might be wrong” is the best process Sizer P, Brismee JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine Underwood M, Buchbinder R. Red flags for back pain. BMJ. 2013 Dec 12;347:f7432. doi: 10.1136/bmj.f7432. pain. Pain Pract. 2007. 31 • Clinicians do not actually screen for red Rethinking Red Flags flags, they manage the findings; • Based on these findings, we propose that clinicians consider: • Red flag symptomology negates the utility of • (1) the importance of watchful waiting; clinical findings; • (2) the value-based care does not support clinical examination • Tests lack the negative driven by red flag symptoms; likelihood ratio to serve as a screen; • (3) the recognition that red flag symptoms may have a stronger • Clinical practice relationship with prognosis than diagnosis. guidelines do not include specific processes that aid decision-making. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2017 Sep 18. pii: bjsports-2017-098352. Br J Sports Med. 2017 Sep 18. pii: bjsports-2017-098352. Categorizing Red Flags Category I: • Category I: Factors which Require Immediate Medical • Blood in Sputum Attention • Elevated Sedimentation Rate • Category II: Factors which Require Subjective Questioning • Loss of Consciousness or Altered mental state and Precautionary Examination and Treatment Procedures • Bowel and Bladder Dysfunction • Category III: Factors which Require Further Physical Testing and Differentiation Analysis • Severe Non-mechanical pain • Progressive Neurological Deficit • Heart-Related Symptoms Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. 35 2007, 2012. 36 6 9/6/2018 Category II: Category III: • Age > 50 • Impairment precipitated by recent • Myelopathic Symptoms trauma • Clonus • Abnormal Reflexes • Long-term corticosteroid use • Fever • Bilateral or Unilateral Radiculopathy or Paresthesia • Gait Deficits • Long-term worker’s compensation • Unexplained Referred Pain • History of a disorder with • Non-healing sores or wounds predilection for infection or • Recent history of unexplained • Unexplained Significant Upper or Lower Limb Weakness hemorrhage weight loss • History of a metabolic bone • Writhing pain disorder • History of cancer Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007, 37 38 2012. Best Tests for Upper Quarter Red Flags Fractures Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University Canadian C-Spine Canadian C-Spine Rules Rules • Sensitivity of the Canadian C-spine rule ranged from 0.90 to 1.00 with negative predictive values ranging from 99 to 100%. Sensitivity = 99 • Inter-rater reliability of the Canadian C-spine rule varied from k = 0.60 between nurses and physicians to k = 0.93 among paramedics. Stiell et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and Moser et al. Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk economic analysis). Ann Emerg Med. 2001;38(3):317-22. 41 patients with blunt trauma to the neck: part 2. Eur Spine J.
Load more

Recommended publications
  • 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
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • 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%).
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions
    Review Article Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Its Joseph C. Schaffer, MD superficial anatomy enables diagnosis of the injury through a thorough history and physical examination. Examination techniques for the knee described decades ago are still useful, as are more recently developed tests. Proper use of these techniques requires understanding of the anatomy and biomechanical principles of the knee as well as the pathophysiology of the injuries, including tears to the menisci and extensor mechanism, patellofemoral conditions, and osteochondritis dissecans. Nevertheless, the clinical validity and accuracy of the diagnostic tests vary. Advanced imaging studies may be useful adjuncts. ecause of its location and func- We have previously described the Btion, the knee is one of the most ligamentous examination.1 frequently injured joints in the body. Diagnosis of an injury General Examination requires a thorough knowledge of the anatomy and biomechanics of When a patient reports a knee injury, the joint. Many of the tests cur- the clinician should first obtain a rently used to help diagnose the good history. The location of the pain injured structures of the knee and any mechanical symptoms were developed before the avail- should be elicited, along with the ability of advanced imaging. How- mechanism of injury. From these From the Division of Sports Medicine, ever, several of these examinations descriptions, the structures that may Department of Orthopaedics, are as accurate or, in some cases, University of Rochester School of have been stressed or compressed can Medicine and Dentistry, Rochester, more accurate than state-of-the-art be determined and a differential NY.
    [Show full text]
  • Sacroiliac Joint Dysfunction a Case Study
    NOR200188.qxd 3/8/11 9:53 PM Page 126 Sacroiliac Joint Dysfunction A Case Study CPT William Murray Pain is a widespread issue in the United States. Nine of physical therapist. She was evaluated and her treatment 10 Americans regularly suffer from pain, and nearly every consisted of a transcutaneous electrical nerve stimula- person will experience low back pain at one point in their lives. tion unit while in the PT clinic, aqua therapy, and ice Undertreated or unrelieved pain costs more than and heat application. $60 billion a year from decreased productivity, lost income, After several weeks, Ms. T returned to the primary care and medical expenses. The ability to diagnose and provide ap- provider and informed her that the pain has not decreased and “feels like that it is getting worse.” She also informed propriate medical treatment is imperative. This case study ex- the provider that she was having difficulty sleeping and amines a 23-year-old Active Duty woman who is preparing to constantly feeling tired secondary to pain. Throughout the be involuntarily released from military duty for an easily cor- next several months, the primary care provider tried nu- rectable medical condition. She has complained of chronic low merous medication trials with no relief for the patient. Ms. back pain that radiates into her hip and down her leg since ex- T gives a history of being prescribed numerous medica- periencing a work-related injury. She has been seen by numer- tions within several drug classifications. She stated vari- ous providers for the previous 11 months before being referred ous side effects that are related to the medications and to the chronic pain clinic.
    [Show full text]
  • Mcmaster Musculoskeletal Clinical Skills Manual 1E
    McMaster Musculoskeletal Clinical Skills Manual Authors Samyuktha Adiga Dr. Raj Carmona, MBBS, FRCPC Illustrator Jenna Rebelo Editors Caitlin Lees Dr. Raj Carmona, MBBS, FRCPC In association with the Medical Education Interest Group Narendra Singh and Jacqueline Ho (co-chairs) FOREWORD AND ACKNOWLEDGEMENTS The McMaster Musculoskeletal Clinical Skills Manual was produced by members of the Medical Education Interest Group (co-chairs Jacqueline Ho and Narendra Singh), and Dr. Raj Carmona, Assistant Professor of Medicine at McMaster University. Samyuktha Adiga and Dr. Carmona wrote the manual. Illustrations were done by Jenna Rebelo. Editing was performed by Caitlin Lees and Dr. Carmona. The Manual, completed in August 2012, is a supplement to the McMaster MSK Examination Video Series created by Dr. Carmona, and closely follows the format and content of these videos. The videos are available on Medportal (McMaster students), and also publicly accessible at RheumTutor.com and fhs.mcmaster.ca/medicine/rheumatology. McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona McMaster Musculoskeletal Clinical Skills Manual TABLE OF CONTENTS General Guide 1 Hip Examination 3 Knee Examination 6 Ankle and Foot Examination 12 Examination of the Back 15 Shoulder Examination 19 Elbow Examination 24 Hand and Wrist Examination 26 Appendix: Neurological Assessment 29 1 GENERAL GUIDE (Please see videos for detailed demonstration of examinations) Always wash your hands and then introduce yourself to the patient. As with any other exam, ensure adequate exposure while respecting patient's modesty. Remember to assess gait whenever doing an examination of the back or any part of the lower limbs. Inspection follows the format: ● S welling ● E rythema ● A trophy ● D eformities ● S cars, skin changes, etc.
    [Show full text]