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Home , Barlow maneuver, Drawer test, Lachman test, McMurray test, Range of motion, Valgus stress test

Pearls in the Musculoskeletal Exam

Frank Caruso MPS, PA-C, EMT-P Skin, , 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 • • • 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 • to bone: This is hard, unyielding – normal would be extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and 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. Abnormal End Feel

• Bone to bone: similar to normal bone – to bone but the restriction or sensation of restriction occurs before the normal end of range of movement • Empty: detected when considerable pain is produced by movement - - no real mechanical resistance – acute bursitis – neoplasm. Abnormal End Feel

• Springy block: similar to a tissue stretch – occurs where one would not expect it to occur – usually found in joints with menisci. There is a rebound effect – example: would feel a springy block end feel with a torn of a knee when it is locked or unable to go into full extension (usually no muscle spasm).

Range of Motion

• Active ROM and passive ROM for each joint and related muscle group • Note – Pain – Limited or spastic movement – Joint instability – Deformity – Contracture Range of Motion

• Passive ROM may exceed active ROM by 5 degrees. • Active ROM and passive ROM should be equal in contralateral joints. • Discrepancies may indicate muscle weakness or disorder. • Use goniometer where there is increased or limited ROM.

Examination and Findings Equipment

• Marking pencil • Goniometer • Tape measure • Reflex hammer • Inclinometer • Mono-filament Goniometry

• Is most appropriate for the measurement of medium and small appendicular joints • The examination procedure and techniques used must be consistent Lets Put It All Together!!

Joint by Joint My Shoulder Hurts!! Shoulder ICD-9 ICD 10

• Shoulder pain – 719.41 • Shoulder pain – M25.51 • Rotator cuff sprain - • Rotator cuff sprain - 840.4 S43.4 • Rotator cuff tendonitis • Rotator cuff tendonitis – 726.10 – M75.1 Shoulder/Scapula

34

36 Supraspinatus

37 38 Infraspinatus

39 Teres Minor

40 Subscapularis

41 Exam & Findings: Shoulders • Inspect – Shoulder girdle, Clavicle, and Scapula for: – Size – Symmetry – Contour – Dislocation/winging of scapula

• Palpate – Sterno-clavicular joint – Acromioclavicular joint – Shoulder muscles – Biceps Groove Exam & Findings: Shoulders • Assess Active and Passive ROM – Forward flexion • The arm is kept straightened and brought upward through the frontal plane, and moved as far as the patient can go above his head. Note: for recording purposes, 0 degrees is defined as straight down at the patient's side, and 180 degrees is straight up Exam & Findings: Shoulders • Assess Active and Passive ROM – External rotation (hands behind head) – The patient is positioned sitting and the elbow is flexed 90 degrees – While the elbow is held against the patient's side, the examiner externally rotates the arm as permitted Exam & Findings: Shoulders • Assess Active and Passive ROM – Extension Exam & Findings: Shoulders • Assess Active and Passive ROM – Abduction Adduction Shoulder Assessment

• Several procedures are used to evaluate rotator cuff for impingement or tear―increased pain associated with inflammation or tear • Neer test – Internally rotate and forward flex arm at the shoulder: presses supraspinatus muscle against anteroinferior acromion Shoulder Assessment

• Hawkins test – Forward flexing shoulder to 90 degrees, flexing elbow to 90 degrees, and then internally rotating arm to its limit Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation. Supraspinatus examination ("empty can" test). The patient attempts to elevate the arms against resistance while the are extended, the arms are abducted and the thumbs are pointing downward. Infraspinatus/teres minor examination.

The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees. Subscapular Muscle Testing • Push off • Largest part of the rotator cuff

52 Test Maneuver Diagnosis suggested by positive result

Apley scratch Patient touches superior and inferior aspects of opposite Loss of range of motion: rotator cuff test scapula problem Neer's sign Arm in full flexion Subacromial impingement Hawkins' test Forward flexion of the shoulder to 90 degrees and internal Supraspinatus tendon impingement rotation Drop-arm test Arm lowered slowly to waist Rotator cuff tear

Cross-arm Forward elevation to 90 degrees and active adduction Acromioclavicular joint arthritis test Apprehension Anterior pressure on the humerus with external rotation Anterior glenohumeral instability test Relocation Posterior force on humerus while externally rotating the arm Anterior glenohumeral instability test Sulcus sign Pulling downward on elbow or wrist Inferior glenohumeral instability

Yergason test Elbow flexed to 90 degrees with forearm pronated Biceps tendon instability or tendonitis

Speed's Elbow flexed 20 to 30 degrees and forearm supinated Biceps tendon instability or tendonitis maneuver "Clunk" sign Rotation of loaded shoulder from extension to forward flexion Labral disorder Probable Finding diagnosis

Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction Seizure and inability to passively or actively rotate Posterior shoulder dislocation affected arm externally Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment

Pain radiating below elbow; decreased cervical range Cervical disc disease of motion Shoulder pain in throwing athletes; anterior Glenohumeral joint instability glenohumeral joint pain and impingement

Pain or "clunking" sound with overhead motion Labral disorder

Nighttime shoulder pain Impingement

Generalized ligamentous laxity Multidirectional instability IMPINGEMENT

55 Patient Symptoms: Impingement

• I can’t sleep at night, my shoulder is killing me • It is too painful to raise up my arm • It feels like my bones are rubbing together • My arm is painful and weak • My shoulder, neck and arm are hurting me

56 Exam Summary:

• Pain with painful arc maneuver – subacromial impingement • Focal subacromial tenderness • Painless testing of resisted abduction (supraspinatus), external rotation (infraspinatus), adduction ( subscapularis), and elbow flexion (Biceps) • Normal range of motion of the glenohumeral joint • Preserved strength in all directions

57

ROTATOR CUFF TENDONITIS

62 Patient Symptoms: Rotator Cuff Tendonitis • I can’t reach up my back anymore • Whenever I move in certain directions I get a sharp deep pain in my shoulder • My arm feels better by hanging it over the bed

63 Exam Findings:

• Focal subacromial tenderness • Subacromial impingement, a positive painful arc test • Positive Flexion Abduction Resistance (FAR) • Normal range of motion of glenohumeral joint • Preserved rotator cuff strength – no gross weakness

64 ADHESIVE CAPSULITIS – FROZEN SHOULDER

65 Patient Symptoms: Adhesive Capsulitis • My shoulder is stiffening up • I can’t reach up over my head • Its getting harder and harder to put my coat on • My shoulder used to be painful, pain has improved by I can’t move it now

66 Exam Summary

• Loss of external rotation with elbow at side • Restricted abduction • My shoulder makes this terrible clunking noise • No radiographic evidence of glenohumeral

67

ROTATOR CUFF TENDON TEAR

69 Patient Symptoms: Rotator Cuff Tear • I have no strength in my shoulder any more • Every time I roll my shoulder , it pops • I can’t sleep on my back any more, There’s this spot of pain over my shoulder blade

70 Exam Summary:

• Weakness in testing of rotator cuff muscles • Rule out central lesion • Positive drop arm test • High riding humeral head (older patients)

71

ACROMIO-CLAVICULAR STRAIN/OSTEOARTHRITIS

78 Acromioclavicular Joint(AC)

ICD-9 ICD-10 • AC joint pain: 719.41 • AC joint pain: M25.51 • AC joint sprain: 840.0 • AC joint sprain: S43.5 • AC joint subluxation/dislocation: • AC joint 831.04 subluxation/dislocation:S43.1 • AC joint arthritis, unspecified: • AC joint arthritis, unspecified: 716.91 M13.91 • AC joint arthrosis, primary: • AC joint arthrosis, primary: 715.11 M19.01 • AC joint arthrosis, posttraumatic: • AC joint arthrosis, posttraumatic: 716.11 M19.11 • AC joint arthrosis, secondary: • AC joint arthrosis, secondary: 715.21 M19.21 Patient Symptoms : AC Joint

• Whenever I reach up or across my shoulder, I get a pain right here • I fell off my mountain bike and landed right on my shoulder. Ever since then I have had achy pain • If I reach up, I feel a grinding in my shoulder

80 Exam Summary

• AC joint enlargement/tenderne ss • Pain aggravated by downward traction or forced adduction, performed passively • AC joint widening

81

BICEPS TENDONITIS

83

Patient Symptoms: Biceps Tendonitis • The front of my arm hurts when I use it • I get this pain right here whenever I move my shoulder • My shoulder has been sore for a long time. Yesterday, I tried to place my trailer on the hitch when I felt and heart this loud pop • My shoulder used to hurt a lot everyday. Two days ago, it stopped hurting. What is this large bruise near my elbow?

85 Exam Summary

• Local tenderness in the bicipital groove • Pain aggravated by flexion of the elbow • A bulge in the antecubital fossa, possible rupture of the long head tendon.

86

Scapulothoracic Syndrome

ICD-9 ICD10 • Bursitis of shoulder: 727.3 • Bursitis of shoulder: M75.5 • Specified injury to scapula: • Specified injury to scapula: 719.48 S49.8 • Unspecified injury to • Unspecified injury to scapula: scapula: 959.2 S49.9 • Other specified arthropathy of • Other specified arthropathy scapula: M19.81 of scapula: 716.81 • Unspecified arthropathy of • Unspecified arthropathy of scapula: M19.91 scapula: 716.91 SUBSCAPULAR BURSITIS

89

Exam Findings

• Weakness on muscle testing • Levator scapulae tenderness • Rule out central lesion (cervical nerve root)

91 Patient Symptoms: Subscapular

• My shoulder blade is killing me • My shoulder and neck is hurting me • Sitting at a computer is very painful

92 Exam Summary

• Local tenderness under the superomedial angle of the scapula • Full range of motion of the shoulder • No evidence of cervical root irritation or rhomboid or trapezius muscle strain

93

GLENOHUMERAL OSTEOARTHRITIS

95 Glenohumeral Joint

ICD-9 ICD-10 • Shoulder pain: 719.41 • Shoulder pain: M25.51 • Shoulder adhesive • Shoulder adhesive capsulitis: 726.0 capsulitis: M75.0 • GH joint arthritis, • GH joint arthritis, unspecified: 716.91 unspecified: M 13.91 • GH joint arthrosis, post- • GH joint arthrosis, post- traumatic: 715.11 traumatic: M19.01 • GH joint arthrosis , • GH joint arthroisis , secondary: 715.21 secondary: M19.21 Patient Symptoms: OA

• My shoulder makes a terrible clunking noise, my shoulder is stiff • I can’t do anything with my shoulder • Sleeping is terrible – the slightest move wakes me up at night

97 Exam Findings

• Crepitation with circumduction or clunking sensation with range of motion • Restricted abduction and internal rotation • General fullness of the shoulder

98

MULTI-DIRECTIONAL INSTABILITY

100 Patient Symptoms: Multi- Directional Instability • It feels like my shoulder is going to pop out • Every time I try to lift something heavy, my shoulder seems to slip • I don’t trust my shoulder anymore

101 Exam

• Downward traction on the arm causes the sulcus sign • Increased antero-posterior mobility of the humeral head • A positive apprehension sign when the arm is placed at 70 – 80 degrees of abduction and passively rotated externally

102

SIMON SAYS MY ELBOW HURTS

104 Elbow/Forearm Exam & Findings: Elbows • Inspect – Contour – Carrying angle – Subcutaneous nodules • Palpate elbow, olecranon bursa, and grooves on each side of olecranon for: – Tenderness – Swelling – Thickening Exam & Findings: Elbows • Assess ROM and strength – Flexion – Extension STABILITY

Testing mediolateral elbow stability

To eliminate interfering movements during varus instability testing, the humerus is placed in full internal rotation and the forearm in pronation.

To eliminate interfering movements during valgus instability testing, the humerus is placed in full external rotation.

Valgus testing is done with the forearm pronated, to test the medial collateral ligament, followed by testing in supination, to check the lateral collateral complex. LATERAL EPICONDYLITIS

109 Lateral Epicondylitis

• CPT: 20551 Injection of tendon origin or insertion • ICD-9: 726.32 • ICD-10: M77.1 Patient Symptoms: Lateral Epicondylitis • I can’t even pick up a coffee cup without severe pain • After a couple of hours of using screw driver, my elbow starts to ache badly • I can’t spike the volleyball anymore

111 Exam Summary:

• Local epicondylar tenderness • Pain aggravated by resisting wrist extension • Decreased grip strength • Full elbow range of motion

112

MEDIAL EPICONDYLITIS

114 Medial Epicondylitis

• CPT: 20551 – Injection of tendon origin or insertion • ICD 9: 726.31 • ICD 10: M77.0 Patient Symptoms: Medial Epicondylitis • I losing grip strength, my elbow hurts bad • After a couple of hours of using my computer, my elbow starts to ache really badly

116 Exam Summary

• Local epicondylar tenderness • Pain aggravated by resisting wrist flexion and radial deviation • Decreased grip strength • Full range of motion of the elbow joint

117

OLECRANON BURSITIS

119 Olecranon Bursitis

• CPT Code: 20605 – Aspiration and/or injection of intermediate bursa • ICD-9: 726.33 • ICD-10: M70.2 Patient Symptoms: Olecranon Bursitis • I have this golf ball swelling on the tip of my elbow • I have got this sack of fluid hanging off my elbow • All of a sudden I developed this red, hot , swollen area over my elbow

121 Exam Findings

• Swelling, redness, and heat over the olecranon process • Full rang of motion of the elbow joint • A characteristic aspirate

122

RADIOHUMERAL JOINT DISEASE

125 126 Patient Symptoms: DJD Elbow

• I can’t straighten my arm • I feel a pressure buildup in my elbow • My elbow doesn’t move smoothly anymore. It’s like a ratchet that catches as I try to straighten it • I can’t throw any more. My elbow hurts too much and its getting weaker

127 Exam Summary

• Loss of full flexion, extension, supination or supination • Lack of smooth motion or catching • Lateral joint line tenderness and swelling • Endpoit stiffness or pain

128 RADIAL NERVE ENTRAPMENT

129 Radial Nerve Entrapment: Symptoms • Caused by entrapment of deep branches of the radial nerve • Pain, weakness and dysfunction in the distribution of the radial nerve Exam Findings

• Weakness in the distribution of the radial nerve – Extensor carpi ulnaris – Extensor digiti minimi – Extensor digitorum communis • Put tenderness at point of entrapment

131

CUBITAL TUNNEL ENTRAPMENT ULNAR NERVE

133 Cubital Tunnel Injection

• CPT code: 64450 – injection, nerve block, therapeutic, other peripheral nerve or branch • ICD-9: 354.2 • ICD-10-G56.2

Patient Symptoms: Cubital Tunnel

• I have numbness in my pinky and ring finger • I have weakness in my hand • Every time I hit my elbow I get an electric shock down my arm

136 Exam: Cubital Tunnel

• Positive tines over medial aspect • Muscle atrophy • Weakness in distribution of ulnar nerve distal elbow

137 MY WRIST HURTS~

138 Wrist Joint

ICD-9 ICD-10 • Wrist pain: 719.43 • Wrist pain: M25.53 • Wrist sprain, unspecified: • Wrist sprain, unspecified 842.00 S63.5 • Wrist joint arthritis: 716.93 • Wrist joint arthritis:M13.93 • Wrist joint arthrosis, primary: • Wrist joint arthrosis, primary: 716.13 M19.03 • Wrist joint, post-traumatic: • Wrist joint, post-traumatic 716.13 M19.13 • Wrist joint arthrosis, • Wrist joint arthrosis, secondary: 715.23 secondary: M19.23 Wrist/Hand

Exam & Findings: Hands/Wrists • Assess ROM Wrist – Flexion Extension

– Radial Deviation Ulnar Deviation Exam & Findings: Hands/Wrists • Assess ROM Fingers – DIP, MIP, PIP joint flexion/hyperextension – Finger abduction/adduction – Thumb opposition Exam & Findings: Hands/Wrists • Inspect DIP/PIP joints, MP joints, and wrist joints for: – Contour – Position – Shape – Number/ completeness of digits – Finger deviation Exam & Findings: Hands/Wrists • Palpate joints – hand /wrist – Texture – Swelling – Tenderness – Bogginess – Nodules – Bony overgrowths

Hand and Wrist Assessment

• Several procedures are used to evaluate the integrity of the median nerve. • Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome. Hand and Wrist Assessment

• Thumb abduction test – Isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve. • Tinel sign – Tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament. – Tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign. Hand and Wrist Assessment

• Phalen test – Patient holds both wrists in a fully palmarflexed position with the dorsal surfaces pressed together for 1 minute. – Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. DE QUERVAIN TENOSYNOVITIS

151 Patient Symptoms: Dequervains

• I can’t grip anymore • Everytime I pick something up I get this sharp pain in my wrist • I have had this sharp pain over my wrist ever since I had a IV started • I bone is getting bigger – (pointing to the radial styloid)

152 Exam

• Local tenderness at the tip of the radial styloid • Pain aggravated by resisting thumb extension or abduction • A positive Finklestein test • A distensible tenosynovial sac

153

De Quervain’s

• CPT code: 20550 injection of single tendon sheath • ICD9: 727.04 • ICD10: M65.4 CARPOMETACARPAL OSTEOARTHRITIS(OA)

156 Patient Symptoms: OA Thumb

• I can’t grab anything anymore, my thumbs hurt • My thumbs are starting to look like the arthritis my grandmother had • My thumbs feel better if I put pressure on them when I do my work • I had to stop sewing, knitting or crocheting because of constant pain in my thumbs

157 Patient Symptoms: OA Thumb

• My thumb kills me if I knit too long • I have this bad ache in the base of my thumb • I can’t pick things up any more with my thumb and index • Vibration just kills my thumb

158 Exam

• Compression tenderness across the joint • Crepitation of the joint in circumduction • Pain aggravated at the extremes of thumb motions • Bony deformity, subluxation or both

159 160 GAMEKEEPER’S THUMB

161 Patient Symptoms: Gamekeepers

• I took a fall while skiing. My thumb got caught in my pole strips • My thumb hurts whenever I try to use a hammer

162 Exam

• Local tenderness and swelling along the ulnar side of the MP joint • Pain or excessive motion with valgus stress testing of the ulnar collateral ligament • Decreased pinching strength due to instability or acute pain

163

CARPAL TUNNEL

165 Carpal Tunnel Syndrome: Traditional Approach • CPT code: 20526 Injection of Carpal Tunnel • ICD9: 354.0 • ICD10: G56.0 Patient Symptoms: Carpal Tunnel

• My thumb and first two fingers go to sleep at night • My hand keeps going numb • My hand feels dead. I’ve started dropping things

167 Exam Summary

• Sensory loss in the first three fingers • Loss of thumb opposition • Positive Tinel sign, Phalen sign, or both

168

Trigger finger HAND

171 Trigger Finger • CPT code: 20550- injection of single tendon sheath • ICD9: 727.03 • ICD10: M65.3 Patient Symptoms: Trigger Digit

• My finger keeps catching • I wake up in the morning and my finger is locked and very painful to unlock

173 Symptoms

• Local tenderness at the MCP head • Pain aggravated by stretching the finger in extension • Mechanical locking of the proximal interphalangeal and or interphalangeal joint of the thumb

174

GANGLION

178 Ganglion

• CPT code: 20550 – injection of ganglion cyst • ICD9: Ganglion cyst of joint: 727.41 • ICD10: Ganglion cyst of joint: M67.4 • ICD9: Ganglion cyst of tendon sheath: 727.42 • ICD10: Ganglion cyst of tendon: M67.4 Patient Symptoms: Ganglion

• I had this lump on the back of my wrist for a long time but it recently has grown bigger • My brother in law wanted to hit my wrist with the “Bible” I wouldn’t let him

180 Exam

• Highly mobile, fluctuant cyst that transilluminates light, min tenderness, normal wrist motion, highly viscous aspirate

181

MY HIP HURTS

184 TROCHANTERIC BURSITIS

185 Trochanteric Bursitis

• CPT code: 20551 injection of tendon origin or insertion • ICD-9 : 726.5 • ICD-10: M70.6

Patient Symptoms: Trochanteric Bursitis • Whenever I roll over onto my right side, this sharp pain in my hip wakes me up • I get this aching pain in my hip when I walk to too much in the mall • I can’t stand for very long • Climbing up the stairs has become impossible

189 Exam

• Local mid-trochanteric tenderness • Aggravation of pain at the extremes of hip rotation • Pain aggravated by resisted hip abduction • Normal range of motion of the hip

190 OSTEOARTHRITIS OF THE HIP

191 Patient Symptoms: Hip OA

• I have this deep achy pain in my groin whenever I walk too far • I have to stop and rest every time I stand or walk too long

192 Exam

• Impaired function, loss of normal gain, inability to remove socks, cross the legs, etc • Loss of internal and external rotation with endpoint stiffness and pain

193 MY KNEE HURTS~

194 Knee Legs and

• Inspect. – Landmarks – Concavities – Alignment • Valgus ? Varus? Exam & Findings: Knees • Palpate supraptellar pouch, femoral epicondyles, on each side of patella , over tibiofemoral joint space and popliteal space for: – Swelling – Tenderness – Bogginess – Crepitus Exam & Findings: Knees • Assess ROM – Flexion – Extension • Assess muscle strength Exam & Findings: Knee

• McMurray test – Used to detect a torn medial or lateral meniscus – Flex knee completely, rotate foot to lateral position, and keeping foot in that position, extend the knee to 90 degrees – Not any palpable or audible clicks, grinding, pain, or limited extension of the knee – Flex knee again and repeat procedure with food in medial position McMurray Test Exam & Findings: Knee • Anterior – Used to identify instability of the anterior – With the patient supine, hips flexed and knees flexed to 90 degrees and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings – Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur – Compare both knees – movement greater than 5mm is positive finding Anterior Drawer Test Exam & Findings: Knee

• – Used to evaluate anterior cruciate ligament integrity – With the patient supine, flex the knee to 10-15 degrees with the heel on the table – Place one hand above the knee to stabilize the femur, place the other hand around the proximal tibia – Pull tibia anteriorly – Movement greater than 5mm compared to the uninjured side indicates injury to the ligament Lachman Test Exam & Findings: Knee

• Posterior drawer test – Used to identify instability of the posterior cruciate ligament – Position the patient and place your hands int eh positions described for the anterior drawer test – Push the tibia posteriorly and observe the degree of backward movement in the femur – Movement of the knee greater than 5mm is a positive finding Posterior Drawer Test Exam & Findings: Knee • – Tests the stability of the medial collateral ligament (MCL) – With patient supine and knee slightly flexed, move the thigh about 30 degrees laterally to the side of the table – Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle – Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side – Laxity indicates injury to the meniscus Valgus Stress Test Exam & Findings: Knee • Varus stress test – Test stability of the lateral collateral ligament (LCL) – Knee and thigh in same position as for valgus stress test – Place one hand against the medial surface of the knee and the other around the lateral ankle – Push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side – Laxity in this position indicates injury to the meniscus Varus Stress Test Exam & Findings: Knee

• – Used to determine the presence of excess fluid or an effusion in the knee – Knee extended, apply downward pressure to the suprapatellar pouch – Push the patella sharply against the femur – If effusion is present, fluid will return to the suprapatellar pouch and the patella will float up when pressure is released 212 Exam & Findings: Knee • Bulge sign – Test for excess fluid in the knee – Knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, “milking” fluid downward – Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area – Tap the knee just behind the lateral margin of the patella with the right hand – Observe for a bulge of returning fluid to the hollow area medial to the patella

Knee

ICD:9 ICD:10 • Knee pain: 719.46 • Knee pain • Knee sprain, unspecified • Knee sprain, unspecified site site • Knee arthritis, unspecified • Knee arthritis, unspecified • Knee arthrosis, primary • Knee arthrosis, primary • Knee arthrosis, • Knee arthrosis, posttraumatic posttraumatic • Knee arthrosis, secondary • Knee arthrosis, secondary PATELLOFEMORAL DISEASE

216 Patient Symptoms: Patellofemoral Disease • My knees always have this grinding sound when I bend • Kneeling/squating is just awful • I have troubles going up/down steps • My knees give way all the time • I can’t sit Indian-style anymore

217 Exam Summary

• Painful retro patellar crepitation (squatting, patellar compression) • Full range of motion but with abnormal patellofemoral tracking • Negative apprehension sign for patellar dislocation • Knee effusion - common

218

KNEE EFFUSION

222 Patient Symptoms: Effusion

• My knee is swollen • I feel an egg behind my knee whenever I bed it back • My knee is giving out. • My knee is so swollen I can’t bend it back or fully straighten it.

223 Exam

• General fullness • Synovial milking sign • Posterior popliteal swelling • Patellar ballottement signs • Supra - patellar bulging • Needle aspiration

224

OSTEOARTHRITIS KNEE (OA)

228 Patient Symptoms: Knee OA

• My knee gets stiff and painful at the end of the day • My knees make this awful sound • I can’t bend or straighten my knees anymore • When I was 22 I had cartilage removed - now I have a constant ache.

229 Exam Summary

• Joint – line tenderness (medial, lateral, or at the patella) • Loss of smooth mechanical motion (crepitation) • Loss of full flexion or extension • Knee effusion

230

Bursitis PRE-PATELLAR BURSITIS

237 Patient Symptoms: Knee Bursitis

• My knee is swollen • My have a bump over my knee cap • I bumped my knee against the kitchen cabinet and within hours it had swollen up.

238 Exam Summary

• Swelling and inflammation directly over the inferior portion of the patella • Bursa sac tenderness vs bursa sac thickening • Normal range of motion of the knee unless infection is present.

239 Prepatellar Bursitis PES ANSERINE BURSITIS

241 Pes Anserine Busitis

• CPT code: 20551 – Injection of single tendon origin or insertion • ICD:9 726.61 • ICD:10 M70.5 Patient Symptoms: Pes Anserine

• I have a sharp pain right her – pointing to the inner aspect of the knee) • I sleep with a pillow between my legs because my knee is tender • I can’t sleep on my side. When my knees touch , I get his really sharp pain on the inside of my knee

243 Exam Summary

• Local tenderness in the concavity of the medial tibial plateau directly over the tibial tubercle in the midline • Painless valgus stress testing of the medial collateral ligament

244 BAKERS CYST

245 Patient Symptoms: Bakers Cyst

• I was told that I have a cyst behind my knee • I have this lump behind my knee • I was told in the emergency room I may have a blood clot in the back of my knee

246 Exam:

• A cystic mass in the popliteal fossa • Impaired knee flexion when the cyst is large • Evidence of current or past chronic knee effusion • No evidence of peripheral vascular insufficiency or deep venous thrombosis

247 MEDIAL COLLATERAL LIGAMENT SPRAIN

248 Patient Symptoms: MCL

• I sprained my knee when I tripped on the rug • I was playing touch football when I was tackled from the right side • I was getting out of the bathtub when my leg caught, my body twisted, and my leg was stretched – hurts on the inside of my knee

249 Exam

• Pain aggravated by valgus stress testing • Band of local tenderness located between the medial joint line and the insertion on the tibial • Laxity of the medial collateral ligament • Associated knee effusion, anterior cruciate ligament tear, or medial meniscal tear

250 LATERAL COLLATERAL LIGAMENT

251 Symptoms: Lateral Collateral

• Swelling pain outside of knee • Lateral force, falling off horse, sitting on leg, etc

252 Exam:

• Little effusion • Lateral knee tenderness • Pain increased on varus stress

253 MENISCAL TEAR OF THE KNEE 254 Symptoms

• My knee locks up whenever I get it in certain bent positions • My knee catches • I can’t squat anymore • If I twist just right, I get this real sharp pain • Whenever I shift my weight I felt this loud pop and immediate sharp pain on the inside of my knee

255 Exam

• Loss of smooth motion of the knee • Inability to squat or kneel • Palpable popping on the joint line • Joint effusion

256

ANTERIOR CRUCIATE LIGAMENT INJURY

259 Patient Symptoms: ACL

• I felt a large pop when I got injured playing sports • My knee really swelled up a great deal • I think I have a “trick knee” since I injured it a few years ago • I can’t trust my kneel it feels unstable

260 Exam

• Significant effusion • Positive anterior drawer • Positive lachman • Positive pivot shift

261 SIMON SAYS MY ANKLE/FOOT HURTS

262 Ankle/Foot Exam & Findings: Feet/Ankles • Inspect – Contour/position – Toe deformities – Alignment – Weight bearing – Arch Feet and Ankles • Inspect. – Contour and position – Size and number of toes – Alignment – Weight bearing – Arch • Palpate. – Heat – Swelling – Tenderness Exam & Findings: Feet/Ankles • Palpate anterior surface of ankle joint, achilles tendon, and metatarsal heads for: – Heat – Swelling – Tenderness • Palpate M.P Joint Compression Exam & Findings: Feet/Ankles • Assess ROM – Dorsiflexion/plantar flexion – Inversion/eversion – Abduction/adduction – Flexion/Extension of toes • Assess muscle strength – All the above against resistance – Flexion/Extension of big toe against resistance Flexion/Extension of Ankle Adduction/Abduction of Ankle Inversion/Eversion of Ankle ANKLE SPRAIN

271 Patient Symptoms: Ankle Sprain

• I twisted my ankle playing sports • I stepped off a high curb and came down on the side of my ankle • I injured my ankle years ago, and it has been weak ever since • I sprained my ankle fours weeks ago – was very black and blue - feeling better now but is weak

272 Exam

• Tenderness, swelling, or bruising anterior and inferior to the lateral maleolus • Pain aggravated by forced inversion of the foot • Ankle instability - positive drawer sign , usually appreciated in recovery phase.

273

ANKLE EFFUSION

276 Symptoms

• I think my ankle is swollen • My ankle feels tight inside • I can’t fit in my shoes anymore

277 Exam

• Anterior swelling or general fullness to the ankle • Anterior joint line tenderness • Loss of painful plantar flexion or dorsiflexion • Characteristic aspirate

278

ACHILLES TENDINITIS

280

Patient Symptoms: Achilles

• I have to stop running after two miles because the back of my ankle begins to hurt • I get a sharp pain through my ankle and up the back of my leg whenever I jump • My shoes feel like they’re rubbing against the bone • My achilles tendon is larger on one side • I was playing basketball and it felt like somebody kicked me!

282 Exam

• Tenderness and “cobblestone “thickening 1 ½ “ above the calcaneus • Pain aggravated by stretching in dorsiflexion • Range of motion of the ankle is otherwise normal • Strength and tendon integrity are intact

283

POSTERIOR TIBIALIS TENOSYNOVITIS

285 Patient Symptoms: Posterior Tibialis • I have this sharp pain around the inside of my ankle whenever I step • There is swelling around the back of my ankle • If I wear tight shoes the inside of my ankle hurts • My ankle hurts when I’m walking in uneven ground

286 Exam

• Local tenderness and swelling just inferior andposterior to the medial malleolus • Pain aggravated by resisting ankle inversion and plantar flexion • Pain aggravated by stretching in eversion • Normal range of motion of the ankle

287

PLANTAR FASCIITIS

290 Plantar Fasciitis

• CPT code: 20550 – injection of aponeurosis • ICD 9: 728.71 • ICD10: M72.2 Patient Symptoms: Plantar Fasciitis • My bottom of my foot kills me in the morning when I first get up • I can’t stand on concrete surfaces anymore • I can’t do my jazzercise any more because of my heel pain

292 Physical Exam

• Local tenderness at the calcaneal origin of the plantar fascia • Pain with calcaneal compression • Achilles tendon inflexibility • Tight heel cords

293

HAGLUND’S DEFORMITY

296 Symptoms:

• I have this bump on the back of my heel • My shoes are always hurting my heel

297 Exam Findings:

• Local tenderness and swelling directly over the posterior calcaneus, normal range of motion

298

Toes How Many Folks in the Audience Have UFS????

301

MORTON NEUROMA

304 Morton Interdigital Neuroma

• CPT code: 64450 – Injection, nerve block therapeutic, other peripheral nerve or branch • ICD-9: 355.6 • ICD-10: G57.6 Symptoms: Neuroma

• My two toes have gone numb, I have sharp pain between my toes

306 Exam Findings

• Maximum tenderness in the web space, pain aggravated by the MTP squeeze sign, loss of sensation along the inner aspects of the adjacent two toes

307

Symptoms: Gout

• I woke up in the night with severe, sharp pain in my big toe, my big toe is very red and swollen

310 Exam Findings

• Acute swelling, redness, and heat arising from the MTP joint, severe tenderness at the MTP joint, pain aggravated by even the slightest movement of the joint

311

THE END!!

Some Extra Stuff!!

313

•

Infants/Children/ Adolescent Orthopedics Infants

You know those little annoying things!!!! Infants and Children

• Long bones increase in length and thickness throughout childhood. • Cartilage in smaller bones ossifies. • Ligaments are stronger than bones until adolescence. – Fractures common • Muscle fibers lengthen. • Skeletal system grows. Infants

• Inspect general – Posture – Spontaneous generalized movements • Inspect back. – Hair tufts and dimples – Discolorations – Cysts or masses near spine – Curvature of spine Infants

• Palpate spine. – Shape – Formation

• Palpate muscles and joints. – Tone – Mobility – Subluxation or dislocation Infants

• Assess motor development. – Fine – Gross • Assess ROM. • Assess muscle strength. • Assess tibial torsion. Infants and Children

• Muscular dystrophy – Group of genetic disorders involving gradual degeneration of the muscle fibers • Scoliosis – Concave curvature of the anterior vertebral bodies, convex posterior curves, and lateral rotation of the thoracic spine • Radial head subluxation – Known as nursemaid’s elbow, this is a dislocation injury. Infants

• Barlow-Ortolani maneuver to detect hip dislocation or subluxation should be performed each time you examine the infant during the first year of life. Infants • – Position yourself at the supine infant’s feet, and flex the hip and knee to 90 degrees. – Grasp the leg with your thumb on the inside of the thigh, the base of the thumb on the knee, and your fingers gripping the outer thigh with fingertips resting on the greater trochanter. – Adduct the thigh and gently apply downward pressure on the femur in an attempt to disengage the femoral head from the acetabulum. – A positive sign is when a clunk or sensation is felt as the femoral head exits the acetabulum posteriorly. Infants

• Ortolani maneuver – Slowly abduct the thigh while maintaining axial pressure. – Fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. – If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation. Infants and Children

• Clubfoot (talipes equinovarus) – Fixed congenital defect of the ankle and foot • Metatarsus adductus – Most common congenital foot deformity – Metatarsus adductus can be either fixed or flexible. • Legg-Calvé-Perthes disease – Avascular necrosis of the femoral head

Children

• Assess motor development. – Fine – Gross • Assess ROM. • Inspect: – Spine curvature – Sitting posture – Foot arch – Alignment of feet and legs Children

• Evaluate for the following: – Bowlegs (genu varum) – Knock-knees (genu valgum) • Palpate bones, muscles, and joints. • Evaluate rising from seated position. Adolescents Adolescents

• Rapid growth in puberty results in: – Decreased strength in epiphyses – Increased risk for injury • Bone growth completed about age 20 • Peak bone mass achieved at age 35 Adolescents

• Osgood-Schlatter disease – Traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle • Slipped capital femoral epiphysis – Disorder in which the capital femoral epiphysis slips over the neck of the femur Slipped Capital Femoral Epiphysis

• SCFE – Sudden or gradual displacement of femoral head through physis. – Typically during adolescent growth spurt.

• Predisposing factors – Obesity – Male gender – Sports – Femoral retroversion – Hypothyroidism and growth hormone deficiency Slipped Capital Femoral Epiphysis • Mean age at presentation – 12 years for girls (range:10-14 years) – 13 years for boys (range: 11-16 years) – Onset before or after typical range is associated with endocrinopathy. • Bilateral involvement seen in 40- 50% – Not always affected simultaneously • May be acute or chronic – Early detection and treatment imperative Slipped Capital Femoral Epiphysis: Presentation • Who? – 7 – 14 year old – Growing FAST (or about to) – Obese or active more likely What c/o? – ANY hip/thigh/knee pain – Limp – Sits/runs/walks funny Slipped Capital Femoral Epiphysis

• Symptoms – Pain worse with activity • Localized to anterior thigh or knee. – May be unable to bear weight • Exam – Loss of hip internal rotation • Further reduction of internal rotation with hip flexion. – Loss of abduction and extension – Affected extremity usually shorter by 1-3 cm.

337 Slipped Capital Femoral Epiphysis

Loss of internal rotation when hip is flexed to 90° The femoral head is posterior to its normal position, so the flexed hip must externally rotate to keep the head within the acetabulum. Slip is always posterior and often medial

338 Slipped Capital Femoral Epiphysis

• Diagnostic tests – AP and frog-leg lateral radiographs of pelvis – AP view may appear normal • Severity important in treatment and prognosis • Severity is estimated by the percentage of femoral neck left exposed: – Mild- less than 25% – Moderate- 25-50% is moderate – Severe- more than 50% 340 Slipped Capital Femoral Epiphysis • Mean age at presentation – 12 years for girls (range:10-14 years) – 13 years for boys (range: 11-16 years) – Onset before or after typical range is associated with endocrinopathy. • Bilateral involvement seen in 40-50% – Not always affected simultaneously • May be acute or chronic – Early detection and treatment imperative

341 Slipped Capital Femoral Epiphysis

342 Slipped Capital Femoral Epiphysis: Final Thoughts • Treatment: – Non-weight Bearing! – Ortho Consult within 72 hours – This can be bad! • Watch Out for: – Legg-Calve-Perthes – Septic/Toxic Synovitis

343 Adolescents

• Same examination procedures as for adult • Note presence of scoliosis. • Note slight kyphosis or rounded shoulders. Scoliosis

• Lateral curvature of the spine • Usually consists of two curves, the original abnormal curve and a compensatory curve in the opposite direction Scoliosis

• Lateral curvature of the spine of > 10° – Small curves are not scoliosis • Thoracic or lumbar spine (occasionally both) – Associated vertebral rotation with kyphosis or lordosis • May be congenital – Vertebral anomalies • Commonly idiopathic • May be secondary to other disorder • Cerebral palsy • Muscular dystrophy • Myelomeningocele

346 Scoliosis Scoliosis Evaluation

• Is there a curve? • Is it structural? • Is it idiopathic? • How large is the curve? • How mature is the patient? Is there a Curve?

349 Is the Curve Idiopathic?

• Congenital – Vertebral anomalies • Neuromuscular – Cerebral Palsy – Myelomeningocele – Muscular dystrophy – Polio • Miscellaneous – Post surgical – Marfan syndrome – Trauma Idiopathic Scoliosis

• Develops in early adolescence – Male = female in curves < 10° – Female 7X more likely to have significant, progressive curve requiring treatment. – Progression typically girls at age 10-16 years. – Not associated with pain. • Pain suggests primary condition and requires further evaluation.

Curve size Girls:Boys 6-10° 1:1 11-20° 1.4:1

>21° 5.4:1

*JBJS 60A:173,1978

351 Scoliosis

• Physical exam – Forward bending test • Observe from behind • Elevation of rib cage, scapula or paravertebral muscle mass positive finding. – Also assess • Skin • Leg length • Feet alignment • Neuromuscular status – Beware! • Left side thoracic curves have high incidence of spinal cord abnormalities.

352 Scoliosis

353 Is there a curve?

Inclinations of more than 5°-7° require further evaluation

354 Is there a curve?

355 Is the curve structural?

• Postural curves – Pain – Leg length inequality – Behavioral

Beware! • Unusual curves – Left thoracic curves • Unusual symptoms – Significant pain – Radiculopathy • Unusual findings – Neurologic deficit – Skin changes – Hair patches – Asymmetry of lower extremities

359 Congenital Scoliosis

360 Scoliosis Treatment

• If angle < 50° at skeletal maturity – Progression usually ceases. • If angle > 60° at skeletal maturity – progression into adulthood common and may compromise respiratory function. • Unusual if angle less than 90° and healthy • Back pain may occur in adulthood. – Not usually a major disability

361 Pregnant Women

• Increased mobility of pelvic joints – Hormones • Progressive lordosis of spine – Compensate for enlarging uterus • Lower back pain • Muscle cramps Pregnant Women

• Postural changes – Lordosis – Forward cervical flexion – Waddling gait • Assess for: – Lumbosacral hyperextension • Causes lower back pain – Carpal tunnel syndrome • Secondary increased fluid retention Older Adults

• Loss of – At risk for fractures • Deterioration of joint cartilage – Decreased mobility Older Adults

• Weakness – Onset – Associated symptoms • Increases in minor injuries • Change in ease of movement • Nocturnal muscle spasm • History of injuries or excessive use of a joint or group of joints, claudication, known joint abnormalities • Previous fractures Older Adults

• Muscle mass decreases: – Muscle tone and strength decrease. – Reaction time and speed decrease. – Endurance decreases. • Sedentary lifestyle promotes degeneration of musculoskeletal system. Older Adults

• Assessment of activities of daily living for fine and gross motor skills • Osteoporosis Risk Assessment Instrument to screen for osteoporosis • Inspect: – Dorsal kyphosis – Base of support broader (feet more widely spaced) – Reduction in total muscle mass Older Adults

• Palpate muscle for the following: – Tone – Atrophy • Assess muscle strength and ROM. Think Prevention!!!

Osteoporosis Fragility Fractures Men and Women!!! Thank you!

• Any questions/comments please email: Frank Caruso MPS, PAC – [email protected] – [email protected] References

• Anderson, Bruce. Office Orthopedics for Primary Care Diagnosis and Treatment. Saunders. 1999 • Hoppenfeld, Stanley . of the Spine and Extremities. Appleton-Century Crofts. 1976 • McNabb, James A Practical Guide to Joint and Soft Tissue Injection and Aspiration , 2010. Lippincott Williams and Wilkins. Second Edition • Saunders, S; Longworth, S. Injection Techniques in Orthopaedics and Sports Medicine 2009. Churchill Livingston – Third Edition