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Knee Physical Exam and Disclosures: None Injection Skills

Carlin Senter, MD Henry Crevensten, MD Associate Professor Associate Professor of Medicine, UCSF Primary Care Medicine Deputy Director Primary Care UCSF Medicine and Orthopaedics San Francisco VA Health Care System UCSF Essentials of Women’s Health 7/2/19 2 Presentation Title

2 Anatomy 4 bones 3 articular surfaces 4 2 menisci 3 articular surfaces 4 ligaments

PCL LCL MCL ACL Articular

2 menisci (or meniscuses) Musculoskeletal work-up

istory • Medial and lateral . H • Shock absorber . Inspection • Stabilizer . Palpation . . Other Tests Most common knee problems in US adults Common causes of by location of Patellofemoral pain tear OA syndrome (PFPS) symptoms Age Younger Young- middle age Older or h/o . Anterior . Medial trauma - Patellofemoral syndrome - line: or OA Activity Overuse Acute or degenerative Acute or overuse - Quadriceps tendinitis - MCL - Patellar tendinitis - Pes anserine Swelling Soft tissue (no effusion) +/- effusion +/- effusion If torsional instability think tear. - Patellar / quad tear . Posterior Locking May endorse but usually If bucket handle tear May endorse but . Lateral - tendinitis crepitus usually crepitus - Joint line: meniscus tear or OA - Gastrocnemius Instability Pain may lead to this Not usually Preceded by pain - IT band syndrome - Meniscal root tear esp. down hills/ stairs - LCL sprain (rare) - OA, meniscus tears, effusion, popliteal cyst….

The essential knee exam To identify patellofemoral pain, OA and meniscus tears . Standing: Inspection (varus, valgus or neutral) . Seated - Palpation of joint lines (and in doing so palpating distal , proximal ) - Examine for quad atrophy (by having patient straighten legs, compare side to side) The essential knee exam . Supine - Palpation of patellar facets Bonus maneuvers - supine - Evaluate for effusion 1. Lachman (ACL) - Range of motion: flexion, extension 2. Valgus stress (MCL) - McMurray test (meniscus) 3. Varus stress (LCL) 4. Posterior drawer (PCL) . Standing: and Thessaly tests (meniscus) Standing: Inspection Seated: Joint line tenderness (JLT)

Femur

Lateral joint line Medial joint line

Tibia

Fibula

Medial: Sensitivity 83%, Specificity 76% http://doctorhoang.wordpress.com/ http://www.kneereplacementlondon.com/patient- Lateral: Sensitivity 68%, Specificity 97% 2010/09/06/valgus-knee-and- information/ / Konan et al. Knee Surg Traumatol Arthrosc. 2009

Supine: Palpation of patellar facets Effusion

Video courtesy of Dr. Anthony Luke Knee range of motion Meniscus: McMurray test Sensitivity medial 65%, Specificity medial 93%

. ROM: normal 0-135 Test for meniscus: - Determine if knee is locking or if ROM is limited due to effusion Internally rotate the tibia and  and/or pain/guarding/stiffness extend lateral meniscus - Locking: think bucket handle Externally rotate the tibia and meniscus. extend  . Urgent xrays, MRI . Urgent referral to sports Pain and / or snap/click at the surgeon for joint line = concerning for meniscus tear

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008. Video courtesy of Dr. Anthony Luke

Composite exam: JLT + McMurray Lachman test for ACL Sensitivity 75-100%, specificity 95-100%

. JLT more sensitive than McMurray for meniscus tear This is a . McMurray more specific than JLT for meniscus tear negative . Joint line tenderness LR 0.9 for positive exam Lachman test: there is an . McMurray LR 1.3 for positive exam endpoint to . Composite assessment LR 2.7 for positive exam the anterior tibial translation. Solomon DH et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? JAMA. 2001 Oct 3;286(13):1610-20.

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008. Positive Lachman Valgus stress for MCL and Varus stress for LCL

This is a normal exam (no pathologic laxity).

Video courtesy of Drs. Kalli Hose and Anna Quan

Posterior drawer for PCL Standing: Meniscus: squat

. Patient stands flat-footed . Examiner holds their hands for balance . Patient squats as low as possible . (+) If pain or feeling of locking while bent

Sensitivity 75-77%, Specificity 36-42% Snoeker BAM et al. J Orthop Sports Phys Ther. 2015 Sep;45(9):693-702. Standing: Meniscus: Thessaly test

If medial pain when pivot medially then concern for How to do a Knee medial meniscus tear; Injection if lateral pain when pivot laterally then concern for lateral meniscus tear. Carlin Senter, MD Associate Professor Primary Care Sports Medicine University of California San Francisco Video courtesy of Dr. Anthony Luke

Watch: How to do a Knee Injection Video Indications for knee aspiration/injection https://binged.it/2QCSWcw

. Diagnostic - Effusion, esp atraumatic - Send for cell count, differential, crystals +/- gram stain and culture . Therapeutic - - Crystal arthropathy - Inflammatory Intra-articular corticosteroid injections: Contraindications to steroid injection benefits

. Short-term pain relief (6 weeks average) . Joint infection . Small effect on function . Hemarthrosis . No evidence for long-term pain relief . Overlying cellulitis . Clinical effect independent of degree of inflammation present - Don’t need to restrict injection just to those with effusion . Fracture . Frequency: general practice once every 3-4 months max . Prosthetic joint - Concern for cartilage toxicity if given q 3 months x 2 years

Risks of steroid injection in the knee Relative contraindications to steroid injection

. Corticosteroid injection within past 3-4 months . Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days . Facial flushing: 10% with Kenalog . Coagulopathy - 19-36 hours post-injection . Skin or fat atrophy . Poorly controlled diabetes . Post-injection steroid flare: 1-10% - Synovitis in response to injected crystals - Within hours - 48 hours post-injection - More common in soft tissue injections (20% of trigger points) than intra-articular injections . Septic arthritis: 1/3000-1/50,000 - 1-2 days after injection

Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2010. Why aspirate the effusion before injection? Aspiration/injection supplies

• Betadine swab x 3 . Clinically - Decreased pain and stiffness because effusion gone • Ethyl chloride spray - More effect of steroid because not diluted by effusion • Alcohol swabs x 6 - Inspect fluid for inflammation/infection, send to lab if question • - Confirms that injxn was intra-articular 4x4 gauze x 1 . Significantly greater improvement in VAS for patients who had joint aspirated at time • Bandaid x 1 of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.) . Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.)

Needles, syringes, meds Aspiration Superolateral approach Post-injection patient instructions

. Patient supine . Rest: no definitive evidence-based recommendation . Extend knee - Recommendations in literature vary . Bump under knee so flexed 10-20 . No restrictions degrees . Bed rest x 24 hours . Superior border patella . Light activity x 7 days, no weight bearing - I recommend no strenuous activity x 7 days . Lateral border patella . Avoid , hot tub, bath x 24 hours . 1cm below - Let injection site heal . Mark with syringe cover or tip of pen UCSF CME: Essentials of Women’s Health July 2019 The Essential Physical Exam of the Knee for the Primary Care Clinician

Maneuver Notes Standing

 Inspection (knees varus, valgus, neutral, feet pronated or supinated)

Supine

 Palpate patellar facets

 Evaluate for effusion

 Range of motion (flexion, extension)

 McMurray’s test (meniscus)

Supine or Seated: bonus maneuvers

 Valgus stress for MCL at 0 and 30 degrees

 Varus stress for LCL at 0 and 30 degrees

 Lachman test for ACL

 Posterior drawer for PCL

Standing

 Squat (meniscus)

 Thessaly (meniscus)

Shoulder Physical Exam and Disclosures: None Injection Skills

Carlin Senter, MD Henry Crevensten, MD Associate Professor Associate Professor of Medicine, UCSF Primary Care Sports Medicine Deputy Director Primary Care UCSF Medicine and Orthopaedics San Francisco VA Health Care System UCSF Essentials of Women’s Health 7/2/19 2 Presentation Title

Clavicle bony anatomy SC joint

AC joint 3 bones: -clavicle -scapula Shoulder anatomy -humerus Humerus 4 : Scapula -acromioclavicular Glenohumeral -glenohumeral joint -scapulothoracic -sternoclavicular

Slide adapted with permission from Drs. Meg Pearson and Steve Bent Rotator cuff anatomy Shoulder Glenohumeral Stabilizers: Supraspinatus Labrum Subscapularis • Supraspinatus: Abduction • Infraspinatus: ER

• eres Minor: ER T Teres minor Labrum • Subscapularis: IR

Infraspinatus Anterior Posterior

Slide used with permission from Drs. Anna Quan and Kalli Hose

Shoulder Glenohumeral Stabilizers: Most common shoulder problems in US adults Impingement Labral Rotator cuff Adhesive Glenohumeral Capsule tear tear capsulitis joint OA Prevents Age < 40 < 40 ish > 40 40-60 y/o > 60 y/o anterior, Mechanism Overuse Overuse or Overuse or Acute +/- distant h/o acute acute onset trauma inferior and without posterior MOI +/- displacement diabetes Location of Lateral Deep - Lateral Generaliz Generalized pain shoulder Anterior shoulder ed shoulder Stiffness No No No Yes Yes

Slide used with permission from Drs. Anna Quan and Kalli Hose Musculoskeletal work-up

. History . Inspection Shoulder exam . Palpation . Range of motion . Other Tests

The essential shoulder exam Inspection

. Inspection - infraspinatus atrophy, skin findings . Palpation of AC joint, long head biceps tendon . Active range of motion: abduction, forward flexion, external rotation, internal rotation . Passive range of motion: abduction to 90, external rotation at 90, internal rotation at 90 . Impingement: Hawkins test, Neers test . Strength: Empty can test, Belly press test, Resisted external rotation Palpation: AC joint, Biceps tendon Active range of motion

1. Forward flexion 2. Abduction 3. External rotation 4. Internal rotation

Passive range of motion Impingement: Neer’s test

• Neer’s test (Neer by 1. Abduction the ear) (glenohumeral joint allows abduction • Passive from 0 -90°; the rest • pronated and of abduction is due forward flexed to scapulothoracic • Pain indicates motion) subacromial 2. External rotation impingement 3. Internal rotation Impingement: Hawkins test Supraspinatus: Empty can

Arm is abducted in the • Hawkin’s test (Flap arm like a bird) plane of the scapula and thumb pointed to • Passive the ground. Examiner • Shoulder abducted to 90, pushes down on the flexed to 90 and arm, looking for pain internally rotated (rotator cuff tendinitis) and or weakness (possible ).

Slide used with permission from Drs. Meg Pearson and Steve Bent

Subscapularis: Belly press Infraspinatus and teres minor: Resisted external rotation Watch: How to do a Subacromial Shoulder Injection Video https://youtu.be/m3ukkCBTie8 How to Do a Subacromial Shoulder Injection

Carlin Senter, MD Associate Professor Primary Care Sports Medicine University of California San Francisco

Indication: Shoulder impingement. Indication: Shoulder impingement. Neer’s test Hawkins test Benefits of subacromial injections in rotator cuff disease?

. 2003 Cochrane review: maybe small benefit for SA injection for RC disease (impingement, tendinopathy, partial tear) over placebo at 4wks . Randomized 100 impingement syndrome patients . Difficult to pool data . Subacromial injxns (up to 3x, 1 month apart) - Variations in how patients diagnosed . x 6 sessions - Different types of injections . After 1 year both groups 50% better - Different locations of injections (accuracy?) . 10 injxn people crossed over to PT - Various study designs (lack RCTs) . 9 PT people crossed over to injxn

Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Annals Int Med 8/2014. Cochrane Database Syst Rev. 2003.

Risks of corticosteroid use in rotator cuff Risks of steroid injection in the subacromial disease? space

. Patients with ≥ 4 steroid injections had worse outcomes after . Diabetics: increased blood sugar . Facial flushing: 10% with Kenalog surgery for large-massive RTC tear (Watson M. J Bone Joint Surg Br. 1985) - 19-36 hours post-injection . 1 dose steroid in SA space significantly reduces strength of rat . Skin or fat atrophy RTC (both injured and not injured) @ 1 week. No change . Post-injection steroid flare: 1-10% compared to control at 3 and 5 weeks. (Mikolyzk DK et al. J Bone Joint Surg - Synovitis in response to injected crystals Am. 2009) - Within hours - 48 hours post-injection . Patients with 2 or more SA injections in the year prior to - More common in soft tissue injections (20% of trigger points) than intra-articular injections rotator cuff repair were more likely to have revision surgery . Infection: 1/3000-1/50,000 - 1-2 days after injection (Desai VS et al. Arthroscopy 2018)

Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2017. Accessed 12/1/18. Aspiration/injection supplies Needles, syringes, meds

• Betadine swab x 3 . Needle to draw up meds • Ethyl chloride spray . 22g 1.5 inch needle to inject • Alcohol swabs x 6 . 10cc syringe • 4x4 gauze x 1 . 2-5 cc lidocaine • Bandaid x 1 . Steroid (I use 40mg, 1 cc, triamcinolone)

Approach Subacromial injection

1. Posterior Posterior approach Landmarks 2. Lateral . Posterior and lateral borders of acromion Lateral approach most accurate . Coracoid when using landmarks to guide Technique injection, especially in women. . Insert needle at Posterior “soft spot” (Marder et al. JBJS 2012, Ganokroj et al. . Aim parallel to angle of lateral acromion to reach subacromial Orthopedics 2018.) bursa Ganokroj P et al. Orthopedics. 11/2018 . Direct needle towards ipsilateral coracoid Photo courtesy of Anthony Luke, M.D. Subacromial Injection Posterior or lateral approach Lateral approach . Patient sitting up, hands placed in lap . Ask patient to relax shoulder and muscles . Can apply traction to flexed elbow to open subacromial space . Mark midpoint of lateral edge of acromion . Enter 1-1.5” below marked spot . Angle of entry parallel to acromion (directed slightly cephalad and anterior)

UpToDate “Joint aspiration or injection in adults: Technique and indications. Updated Ganokroj P et al. Orthopedics. 11/2018 10/2017. Accessed 12/1/18. UCSF CME: Essentials of Women’s Health July 2019 The Essential Physical Exam of the Shoulder for the Primary Care Clinician

Physical exam checklist

Maneuver Notes

Inspection ‐ infraspinatus atrophy, skin findings

Palpation  AC joint  Long head biceps tendon

Active range of motion, bilateral  Abduction  Forward flexion  External rotation  Internal rotation

Passive range of motion  Abduction to 90  External rotation at 90  Internal rotation at 90

Impingement:

 Hawkins test

 Neers test

Rotator cuff strength:  Empty can  Belly press  Resisted external rotation