Joint Range of Motion
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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. -
Knee Pain in Children: Part I: Evaluation
Knee Pain in Children: Part I: Evaluation Michael Wolf, MD* *Pediatrics and Orthopedic Surgery, St Christopher’s Hospital for Children, Philadelphia, PA. Practice Gap Clinicians who evaluate knee pain must understand how the history and physical examination findings direct the diagnostic process and subsequent management. Objectives After reading this article, the reader should be able to: 1. Obtain an appropriate history and perform a thorough physical examination of a patient presenting with knee pain. 2. Employ an algorithm based on history and physical findings to direct further evaluation and management. HISTORY Obtaining a thorough patient history is crucial in identifying the cause of knee pain in a child (Table). For example, a history of significant swelling without trauma suggests bacterial infection, inflammatory conditions, or less likely, intra- articular derangement. A history of swelling after trauma is concerning for potential intra-articular derangement. A report of warmth or erythema merits consideration of bacterial in- fection or inflammatory conditions, and mechanical symptoms (eg, lock- ing, catching, instability) should prompt consideration of intra-articular derangement. Nighttime pain and systemic symptoms (eg, fever, sweats, night sweats, anorexia, malaise, fatigue, weight loss) are associated with bacterial infections, inflammatory conditions, benign and malignant musculoskeletal tumors, and other systemic malignancies. A history of rash or known systemic inflammatory conditions, such as systemic lupus erythematosus or inflammatory bowel disease, should raise suspicion for inflammatory arthritis. Ascertaining the location of the pain also can aid in determining the cause of knee pain. Anterior pain suggests patellofemoral syndrome or instability, quad- riceps or patellar tendinopathy, prepatellar bursitis, or apophysitis (patellar or tibial tubercle). -
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. -
Direct Anterior Total Hip Arthroplasty Gait Biomechanics at Three and Six Months Post Surgery
DIRECT ANTERIOR TOTAL HIP ARTHROPLASTY GAIT BIOMECHANICS AT THREE AND SIX MONTHS POST SURGERY A THESIS SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI’I IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN KINESIOLOGY AND REHABILITATION SCIENCE AUGUST 2012 By: Ryan J. Moizon Thesis Committee: Iris Kimura, Chairperson Ronald Hetzler Christopher Stickley Keywords: Total hip arthroplasty; kinematics; kinetics TABLE OF CONTENTS List of Tables ii List of Figures iii Part I Introduction 1 Methods 4 Results 7 Discussion 12 Partil Review of literature 19 Appendix A: Data Collection Forms 37 Appendix B: Health History Form 40 Appendix C: WWB THA Informed Consent Form 42 Appendix D: WRB Control Informed Consent Form 53 Appendix F: Control Flyer 62 References 64 LIST OF TABLES Table Page 1. Demographic Data: Means and Standard Deviations for DA THA and Control group 7 2. Walking Velocity: Means and Standard Deviations for DA THA and Control group $ 3. Kinematic Variables: Mean and standard deviations for DA THA and Control group 9 4. Kinetic Variables: Mean and standard deviations for DA-THA and Control groups 11 5. Maximum VGRF: Means and Standard Deviations for DA THA and Control groups 11 LIST OF FIGURES Figure Page 1. Mean Values for Walking Velocity for DA THA and Control groups at initial test, 3 and 6 months post-test 13 2. Mean Values for Hip FlexionlExtension Excursion for DA THA and Control groups at initial test, 3 and 6 months post-test 14 3. Mean Values for Maximum VGRF for DA THA and Control groups at initial test, 3 and 6 months post-test 15 4. -
A Review of the Special Tests Associated with Shoulder Examination Part I: the Rotator Cuff Tests T
0363-5465/103/3131-0154$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 31, No. 1 © 2003 American Orthopaedic Society for Sports Medicine Clinical Sports Medicine Update A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests T. Duncan Tennent,* FRCS(Orth), William R. Beach, MD, and John F. Meyers, MD From Orthopaedic Research of Virginia, Richmond, Virginia Careful examination of the shoulder is an essential component in forming a diagnosis of problems in this area. A number of tests have been described that are claimed to improve diagnostic accuracy by specifically examining one component of the shoulder complex. Many of these tests are eponymous, and there is confusion about not only how to perform them but also what conclusion to draw from the results. This article attempts to clarify the tests used to examine the rotator cuff by presenting them as described by the original authors with the additional aim of providing a source for those wishing to refresh their knowledge without the need to refer to the original source material. © 2003 American Orthopaedic Society for Sports Medicine The shoulder is a complex joint and, by virtue of having a amination of the rotator cuff. In Part II, to be published in large range of motion, is inherently unstable, relying on the March/April 2003 issue of this journal, the discussion the surrounding soft tissue structures for stability. The will center on tests of laxity, stability, and the superior bony joint consists of the glenoid, acromion, and humeral labral, anterior and posterior (SLAP) lesions. -
Heterotopic Ossification of the Elbow
CHAPTER 38 Heterotopic Ossification of the Elbow Seth D. Dodds, MD • Douglas P. Hanel, MD Patient Presentation Indications The formation of ectopic bone about the elbow commonly The primary indication for operative resection of heterotopic presents following elbow trauma, significant neural axis bone and elbow contracture release is lack of elbow motion. injury, or major burns with symptoms of stiffness or complete Once heterotopic ossification has developed and restricted ankylosis.1 By definition, any ossification that forms in tissues elbow motion, it is nearly impossible to regain the lost motion which do not typically make bone is considered ectopic or with conservative measures, such as physical therapy, dynamic heterotopic. Patients who develop heterotopic ossification splinting, radiation therapy, or medication. Surgical resection of about the elbow can present with muscle, nerve, or joint heterotopic bone about the elbow should be considered in related pain, but most often express frustration due to lack of patients who present with an unacceptable loss of flexion/exten- passive and active motion. Loss of elbow motion leads to dra- sion or pronation/supination. Restoration of a functional arc of matic impairment in upper extremity function. For example, motion is the primary goal in active individuals. From a bio- a 50% loss of elbow motion will cause up to 80% impairment mechanical perspective, the functional arc of elbow motion has in upper extremity function.2 been demonstrated to be from 30° to 130° in the flexion/exten- The pathologic process behind ectopic bone formation sion plane and from 55° of pronation to 55° of supination in has not been fully elucidated. -
Basic Approach Knee Examination
A Standardized Approach Basic Approach to the Knee Examination • Inspection • Palpation • Strength Testing Bryant Walrod, MD • Range of Motion Assistant Professor – Clinical Department of Family Medicine • Special Tests Division of Sports Medicine The Ohio State University Wexner Medical Center Knee Examination Inspection • It is important to begin with a standardized • Inspect patient sitting with approach to the knee exam so as to not knees bent. miss anything. ‒ Observe for an obvious dislocation of the patella or • One also needs to ensure adequate knee joint. exposure • Evaluate for an effusion ‒ Have the patient get into shorts to fully versus a bursitis. expose the knee. ‒ It is also important to • Examine sitting up and supine distinguish between intra- articular or extra articular • Compare with contralateral side swelling. 1 Inspection Functional Observation • Observe also for erythema, induration and rashes. • Observe for a J sign • Inspect for scars • Picture of j sign and ‒ may indicate a previous surgery which will influence your physical exam. • Look also for muscle atrophy of the quadriceps, hamstrings and gastrocnemius. Functional Observation Observation • Genu varus • Genu recurvatum • Observe ambulation ‒ Pronation ‒ Pes planus • Genu valgus • Femoral anterversion ‒ Antalgic gait ‒ External rotation of leg 2 Observation Palpation • Start with the patient sitting on the table to knees bent to 90o. • Next have the patient stand • Palpate initially for warmth on one leg. • Then palpate specific structures: ‒ Patella tendon -
Musculoskeletal Examination Benchmarks
Musculoskeletal Examination Benchmarks _ The approach to examining the musculoskeletal system is the same no matter what joint or limb is being examined. The affected and contralateral region should both be completely exposed and examined, observing for side-to-side differences. Inspect Observe alignment and relative sizes of the areas of interest, at rest and in motion Joints Soft tissue Bursae Palpate Tendons Muscles Ligaments Bony prominences Active range of motion Range of motion If active range of motion is abnormal, passive range of motion. Strength testing Directed tests indicated Joint specific maneuvers that support or argue against items on the differential by DDx diagnosis As you perform the exam, look for the cardinal signs of musculoskeletal disease: Swelling: suggests synovial inflammation or joint effusion Tenderness: suggests inflammation or infection Warmth: suggests inflammation or infection Decreased range of motion: suggests one or more of the following Intraarticular joint problems causing pain with both active and passive ROM Tendon or muscle problems causing weakness or pain with active ROM Prolonged disuse of any cause Weakness: suggests one or more of the following Pain causing give-way weakness Tendon or muscle problem Neurologic problem Shoulder Exam Inspect Anterior and posterior shoulder Start at the sternoclavicular joint and move systematically around the shoulder Sternoclavicular joint Clavicle Acromioclavicular (AC) joint Coracoid process: origin of the short head of the biceps Biceps tendon in the bicipital groove. Palpate Subacromial space and rotator cuff: supraspinatus tendon: just below the anterior lateral acromion. infraspinatus tendon: just below posterolateral acromion. teres minor: just -inferior to the infraspinatus subscapularis insertion: just lateral to coracoid at the anterior shoulder Spine of the scapula: origin of the infraspinatus Flexion, also called forward elevation. -
Temporomandibular Joint Disorders (TMD): a Clinical Assessment
3/6/15 Temporomandibular Joint Disorders (TMD): A Clinical Assessment Primary authors: Betsy Mitchel DC, DABCO Cathy Cummins DC, DABCO Ron LeFebvre DC Edited by Ron LeFebvre DC Drawings by Alyssa Salava Reviewed and Adopted by CSPE Working Group (2014) Amanda Armington DC, Daniel DeLapp DC, DABCO, Lac, ND, Stan Ewald DC, Lorraine Ginter DC, Shawn Hatch DC, Ronald LeFebvre DC, Owen T. Lynch DC, Ryan Ondick DC, Joseph Pfeifer DC, Anita Roberts DC, James Strange DC, Laurel Yancey DC, UWS care pathways and protocols provide evidence-informed, consensus-based guidelines to support clinical decision making. To best meet a patient's healthcare needs, variation from these guidelines may be appropriate based on more current information, clinical judgment of the practitioner, and/or patient preferences. These pathways and protocols are informed by currently available evidence and developed by UWS personnel to guide clinical education and practice. Although individual procedures and decision points within the pathway may have established validity and/or reliability, the pathway as a whole has not been rigorously tested and therefore should not be adopted wholesale for broader use. Copyright 2015 University of Western States Do not reprint without permission Temporomandibular Joint Disorders (TMD) Page 1 of 46 Introduction Temporomandibular disorders are a collection of syndromes associated with pain and dysfunction caused by problems with the temporomandibular joint and its associated musculature. Disorders of the temporomandibular joint complex are the most common cause of orofacial pain. (Shephard 2013) Temporomandibular joint dysfunction (TMD) should be considered as a possible cause or contributing factor in patients with jaw pain, face pain or headaches (see CSPE Cervicogenic Headache care pathway). -
Heterotopic Ossification of the Hip
1 Heterotopic Ossification of the Hip Pathogenesis: The basic defect in HO is inappropriate and rapid metaplastic osteogenesis which results in the formation of lamellar corticospongiosal bone. However, both the specific pathophysiology and etiology of HO remain unclear. What induces precursor cells to go through metaplasia and initiate osteogenic activity is still unknown. Similarly the identity of these precursor cells has not been established. Further, it is not known why heterotopic ossification does not materialize in all cases with similar conditions. It seems, though, that there are three requisite conditions for HO to occur. In addition to an osteogenic precursor cell, there must be an inducing agent and a tissue environment that is permissive of osteogenesis. It appears that non-circulating pluripotent mesenchymal cells are most likely the cells which differentiate to become osteoblastic stem cells. This occurs very soon after injury, within 16 hours after experimentally induced trauma to mice femurs. This suggests that significant pathophysiological events may be occurring in the immediate post-traumatic period, while patients are still receiving acute care. Two possible candidates which act as inducing agents have been established. Through in vitro research it has been established that demineralized bone matrix can induce new bone formation via an osteoinductive protein released from the matrix, now known as bone morphogenic protein (BMP). Additionally, prostaglandins have been implicated as inducing agents. Certain tissues (spleen, liver and kidney) suppress bone induction while others (muscle and fascia) permit experimental induction of bone. Local factors present within the permissive tissues may further predispose them to HO. These are hypoproteinemia, venous thrombosis or hemostasis, (local) infection, decubitus ulcers and (micro) trauma. -
Hip Physical Examination
CHAPTER Benjamin G. Domb Adam Brooks 4 Carlos Guanche Physical Examination of the Hip INTRODUCTION of trauma.7 Much detail about the hip pain should be elicited, including the location and severity of the pain, time of onset, As our understanding and treatment of hip pathology improves, specifi c quality, alleviating, aggravating, or associated factors, a systematic, consistent, and reproducible means of clinically whether the pain is focal or diffuse. Additionally, similar pains, evaluating the hip is imperative. While a limp, groin pain, and popping or locking symptoms, night pain, and any accompany- limited internal rotation are often indicators of hip pathology,1 ing numbness or weakness are important to document. Back the hip is overlooked as the original source of pain or pathology pain and hip pain will often coexist, so care should be taken to in 60% of primary hip disorders.2 Hip pain can be ambiguous note the severity of one pain relative to the other. Radicular pain in its nature and origin, and pathologies of the hip and low may exist with either hip or lumbar spine pathology and is unre- back interact with one another and are easily confused. Hip liable as a differentiating factor. However, weakness, numbness, problems can stem from disorders of the paravertebral muscles, and paresthesias in the lower extremity are suggestive of neural which cause soft tissue instability and irregular tension on the compression, often occurring in the lumbar spine. hip.3 Hip pain can also cause back pain by way of muscle con- An inquiry should also be made into any treatment the tractures of the iliopsoas and the hamstrings or through sec- patient has had and its effectiveness. -
Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis
Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis Nasimah Maricar, Michael J. Callaghan, Matthew J. Parkes, David T. Felson, and Terence W. O’Neill ABSTRACT. Objective. Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). Methods. We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2–10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coeffi- k kω cients (ICC), estimated kappa ( ), weighted kappa ( ), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. k Results. Using Landis and Koch criteria, interobserver scores were moderate for patellofemoral k k k joint ( = 0.53) and anserine tenderness ( = 0.48); good for bony enlargement ( = 0.66), quadriceps k k k wasting ( = 0.78), crepitus ( = 0.78), medial tibiofemoral joint tenderness ( = 0.76), and effusion k kω assessed by ballottement ( = 0.73) and bulge