8/7/2013
Physical Exam Skills and Outline Office Procedures in Orthopaedics • Knee exam • Knee aspiration and injection • Shoulder exam • Subacromial bursa injection
UCSF Essentials of Primary Care August 14, 2012 Carlin Senter, M.D.
The quadriceps muscles extend the knee Knee Anatomy
http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/Thigh+and +Leg+-+Lecture+Notes
1 8/7/2013
The quadriceps muscles merge to form the quadriceps tendon… patellar tendon The hamstrings flex the knee
www.hep2go.com
Pes anserine bursa There are 4 main ligaments in the knee
http://meded.ucsd.edu/clinicalmed/joints.htm
2 8/7/2013
Meniscus Knee exam
Common Causes of Knee Pain by Location of Musculoskeletal work-up Symptoms
• Anterior: • Medial • History - Patellofemoral syndrome - Medial joint-line: meniscus tear or OA - Quadriceps tendinitis - MCL sprain • Inspection - Patellar tendinitis - Pes anserine bursitis P • Lateral: • Posterior • alpation - Lateral jointline: meniscus tear - Hamstring tendinitis or OA - Gastrocnemius strain - IT band syndrome • Range of motion - OA, meniscus tears, - LCL sprain (rare) effusion, popliteal cyst…. - Fibular head: fracture (rare) • Other Tests
3 8/7/2013
Palpation of joint line Inspection seated or supine
http://www.rheumors.com/kneeexam/palpation.html http://doctorhoang.wordpress.com/20 http://meded.ucsd.edu/cl 10/09/06/valgus-knee-and-bunion/ inicalmed/joints.htm
Palpation of patella - supine Palpation of patellar facet
Ballottement
4 8/7/2013
Knee range of motion Other Tests: Lachman to evaluate ACL Sensitivity 75-100% Specificity 95-100% • ROM: normal 0-135 – Determine if knee is locking or if ROM is limited due to effusion – Locking: think bucket handle meniscus. • Urgent xrays, MRI • Urgent referral to sports surgeon for arthroscopy
Permission for use provided by th Dr. Charles Goldberg, UCSD Magee, DJ. Orthopaedic Physical Assessment, 5 ed. 2008.
PCL: Posterior Drawer MCL and LCL
5 8/7/2013
Meniscus: McMurray Meniscus: Thessaly
Sensitivity medial 65%, Specificity medial 93% th Magee, DJ. Orthopaedic Physical Assessment, 5 ed. 2008.
Meniscus: Squat Knee exam practice
• Standing: inspection • Supine – Varus or valgus – Patellar facets • Sitting: palpation – Patellar grind – Joint line – ROM – Femoral condyles – Special tests • – Tibial plateau Lachman • Posterior drawer – Fibular head • Varus 0 and 30 • Valgus 0 and 30 • McMurray medial and lateral • Thessaly • Squat
6 8/7/2013
Intra-articular corticosteroid injections: do they work for knee OA? • Good short-term pain relief – Effect size 0.72 at 2 and 3 weeks • No significant effect on function Knee aspiration and injection – Effect size 0.06 • No evidence for long-term pain relief • Clinical effect independent of degree of inflammation present – Don’t need to restrict injection just to those with effusion • Frequency: general practice once every 3 months max – Concern for cartilage toxicity with more than 4/year • AAOS: recommends for short-term pain relief (level II)
Zhang W et al. OARSI recommendations for the management of hip and knee osteoarthritis: Osteoarthritis Cartilage. 2010 Apr;18(4):476-99.
Superolateral approach Injection set-up bucket
• Patient supine • Betadine • Extend knee • Ethyl chloride • Bump under knee so • Alcohol swabs flexed 10-20 degrees • 4x4 guaze • Superior border patella • Bandaids • Lateral border patella • 1cm below • Mark with syringe cover or tip of pen
7 8/7/2013
Injection prep Needles, syringes, meds
Why use local anesthetic with steroid Corticosteroids injection? • Dilute the steroid – Decrease likelihood of steroid atrophy – Decrease irritant nature of steroid crystals causing post-injection flare • Pain relief – Diagnostic and therapeutic (subacromial more than knee) • Floculation: combining steroid and local anesthetic can precipitate crystals. Carefully inspect for precipitate before injection.
8 8/7/2013
Why aspirate the effusion before Aspiration injection? • Clinically – Decreased pain and stiffness because effusion gone – More effect of steroid because not diluted by effusion – Inspect fluid for inflammation/infection, send to lab if question – Confirms that injxn was intra-articular • Significantly greater improvement in VAS for patients who had joint aspirated at time 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.)
Post-injection patient instructions Contraindications to steroid injection
• Rest: no definitive evidence-based • Joint infection recommendation • Fracture – Recommendations in literature vary • Prosthetic joint • No restrictions • • Bed rest x 24 hours Hemarthrosis (theoretically higher risk of • Light activity x 7 days, no weight bearing exercise infection) • Avoid swimming, hot tub, bath x 24 hours • Soft tissue infection overlying joint – Let injection site heal
9 8/7/2013
Relative contraindications to steroid Risks of steroid injection in the knee injection • Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours • Corticosteroid injection within past 4 months after, lasting 5 days • Suppression of hypothalamic pituitary adrenal axis, mild • Coagulopathy (ok if on warfarin but check – Lasts 1-3 days post-injection • Facial flushing: 10% with Kenalog recent INR, make sure not >> 3) – 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 • Possible risk of chondrocyte toxicity with repeated injections
Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2010.
My current knee injection steps Knee injection
1. Patient supine with bump under knee 2. Mark injection site (superior lateral) 3. Betadine x 3 4. Alcohol x 1 5. Ethyl chloride for skin anesthesia 6. Alcohol again 7. 22g needle attached to 10cc syringe containing 5cc of 1% lidocaine without epi 8. Slowly advance and inject lidocaine, 1mm at a time 9. Feel resistance give when in joint 10. Aspirate, make sure fluid straw-colored and clear 11. Keep needle in place, switch syringe 12. Inject 1cc of 40mg kenalog
10 8/7/2013
Underlying Anatomy - Bones Shoulder anatomy Acromion Greater Tuberosity • Humerus Clavicle • Scapula o Glenoid o Acromion o Coracoid o Scapular body • Clavicle • Sternum Glenohumeral Joint Lesser Tuberosity
The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa
Spine of Acromion scapula is at the level of T3
Bottom of scapula is at level of T7
11 8/7/2013
The Rotator Cuff Muscles (SITS) Supraspinatus (Abduction )
The tendons of the rotator cuff muscles reinforce the capsule of the glenohumeral Greater Tubersosity Posterior joint. View
Lesser Tuberosity Infraspinatus Anterior (External rotation) ) View Teres Minor Subscapularis (External rotation) (Internal Rotation)
The Biceps Muscle Shoulder exam • #1 Supination of the elbow (screwing, twisting) • #2 Flexion of the elbow
Long head 3 attachments: • Radial tuberosity (distal) • Glenoid (long head) • Coracoid (short head) Short head
12 8/7/2013
Cervical Spine Neck examination Spurling’s Maneuver
• Inspection • Neck extended • • Head rotated toward Palpate CS affected shoulder • FF and extension • Axial load placed on • Spurlings the cervical spine • Reproduction of patient’s shoulder/arm pain indicates possible nerve root compression
Shoulder examination Shoulder examination • Inspection • Inspection – Patient in gown • Palpation • Palpation • ROM • ROM http://meded.ucsd.edu/clinic • Strength almed/joints2.htm , • Strength permission granted by Dr. – Supraspinatus Charles Goldberg, UCSD SOM – Supra – – Infra and teres Infraspinatus & minor Teres minor – Subscapularis – Subscapularis • Other tests http://meded.ucsd.edu/clinicalmed/joints • Other tests 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM
13 8/7/2013
Range of motion Range of motion
Internal rotation
Abduction External rotation Flexion
Supine shoulder PROM Other tests
• Rotator cuff strength • Impingement tests • Biceps • Labrum • AC joint
14 8/7/2013
Infraspinatus and teres minor = Supraspinatus = abduction external rotation
Supraspinatus
Infraspinatus Teres minor Empty can
Photos from Dr. Christina Allen Photos from Dr. Christina Allen
Subscapularis = internal rotation Subscapularis = internal rotation
Subscapularis Subscapularis Lift-Off Belly press
Photos from Dr. Christina Allen Photos from Dr. Christina Allen
15 8/7/2013
Impingement syndrome Impingement signs
Subacromial bursa Supraspinatus • Inflammation of the subacromial space – The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid bursa
Hawkin’s
Photos from Dr. Christina Allen Neer’s
Biceps Tests: Speeds Biceps Tests: Yergasons
Tests for biceps pathology Tests for biceps pathology (tendinitis, tendinopathy, (tendinitis, tendinopathy, tear) tear)
Palms up, patient pushes Patient supinates (twists up against resistance out) against resistance (resisted elbow flexion) +Test is pain at proximal +Test is pain at proximal biceps tendon biceps tendon Sens = 41%, Spec = 79% Sens = 54%, Spec = 81%
16 8/7/2013
O’Brien’s Test To r/o Labral Tear Testing the AC Joint: • Arm forward flexed to AC Crossover 90° • • Elbow fully extended Tests for AC joint • Arm adducted 10°to osteoarthritis or 15°with thumb down sprain • Downward pressure • Can be done • Repeat with thumb up passively by • Suggestive of labral patient or tear if more pain with physician thumb down • +Test is pain at • Sens = 59-94%, Spec AC joint = 28-92%
Shoulder Exam Hands On Subacromial injection for impingement syndrome Key Components of the Special Tests: Shoulder Exam: • Spurling’s (cervical spine radiculopathy) • Job’s, aka Empty-can (supraspinatus) - Inspection • Lift-off test (subscapularis) - Palpation • Resisted external rotation - Range of Motion: (infraspinatus) • abduction, flexion, ER, IR Hawkins (impingement sign) • - Strength Neers (impingement sign) • - Neurovascular Speeds (biceps) • - Special tests Yergason’s (biceps) • O’briens (SLAP tear) • AC crossover (AC joint OA or sprain)
http://www.youtube.com/watch?v=wr_FBVjHJY8
17 8/7/2013
Impingement syndrome Approach
Subacromial bursa Supraspinatus • Inflammation of the 1. Posterior subacromial space 2. Lateral – The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid bursa
Slide courtesy of Anthony Luke, M.D.
Subacromial Injection Subacromial Injection
Posterior approach Lateral approach Landmarks • Posterior and lateral Landmarks borders of acromion • Lateral border of the • Coracoid acromion Technique • Technique “Insert needle” at Posterior soft spot • Inject 3 mm below lateral • Aim parallel to angle of lateral acromion to reach http://www.aafp.org/afp/2003/0315/p1271.html border of the acromion subacromial bursa • • Direct needle towards Angle needle parallel to opposite nipple plane of the acromion
Slide courtesy of Anthony Luke, M.D. Slide courtesy of Anthony Luke, M.D.
18 8/7/2013
Subacromial Injection Subacromial injection palpation
• 5 – 8 mL combination of local anesthetic solutions • 1 – 2 mL steroid solution
My preferred solution: • 5 mL 1% lidocaine with 1 mL 40 mg/mL triamcinolone
Subacromial injection Thank you
Questions? [email protected]
19