Examining the Overview

Quick approach to MSK Physical Exam problems • History – what does it How to Make Yours Better mean? • Considering the differential diagnosis Anthony Luke MD, MPH Primary Care Medicine: Update 2014 • Physical exam – confirm the diagnosis

Is the patient?

•Age • Occupation/Activity • Recreational, competitive, or elite • Handedness • Past medical history • Family history Manage patient expectations “The patient will tell you what the problem is”

1 Age factor is the Chief Complaint?

Children The BIG THREE • Tendons and ligaments 1. Pain relatively stronger than 2. Instability epiphyseal plate 3. Dysfunction • Insertional overuse injuries • Other complaints: (OSD, SLJ, Sever’s) swelling, numbness Elderly and tingling, • Decreased flexibility decreased • Apoptosis – “programmed” performance cell death; repair affected

Swelling Bone Pain

• Intra-articular vs. • Constant extra-articular • Sharp • Consider onset of • Greater load = swelling greater pain (i.e. 1) Immediate - minutes weightbearing) 2) In 24 hours • May have pressure 3) Insidious - days features

2 Tendon Pain Onset of injury?

• May be present at the start of an activity then “warm-up” •Acute • Sore when the muscle is used • Chronic • Acute on Chronic • May occur in “compensation” for other structural problems near by • Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD

Mechanism of Injury? L i g a m e n t Anatomy and Biomechanics

Ultimate Ligament Tension Failure

• ACL: 2200 N (Anterior) • PCL: 2500 N (Posterior) • MCL: 4000N (Valgus) • LCL: 750N (Varus) • Posteromedial Corner • Posterolateral Corner

3 Biomechanical Studies is the injury located?

Forces on the ACL/Graft • Think about structures • Level Walking = 169 N in injured area • Ascending Stairs = 67 N • Is the pain referred? • Descending Stairs = 445 N • The one-finger test Morrison, Biomech, 1970 Morrison, Bio Eng,1968,1969 • Know your anatomy • Normal Walking = 400 N • Sharp Cutting = 1700 N Butler, Clin Orthop, 1985 • Sports = 2000+ N

Red Flag Symptoms

• Severe disability Intrinsic Risk Factors Extrinsic Risk Factors • Numbness and tingling •Growth • Training • Anatomy • Technique • Night pain • Muscle/Tendon • Footwear • Constitutional symptoms (fever, wt loss) imbalance •Surface • Swelling with no injury • Illness • Occupation • Nutrition • Systemic illness • Conditioning • TO PREVENT • Multiple joint injury • Psychology INJURIES!!

4 First Test - Physical Exam Physical exam

Physical Exam SPECIAL TESTS • Confirms or excludes the suspected LOOK – Observation Provocative tests • Swelling, Erythema, • Reproduce patient’s pain diagnosis Atrophy, Deformity, • Tests are often non-specific Surgical Scars (SEADS) Stress tests • Stress structures for • Groups of tests can improve sensitivity FEEL – Palpate important instability (i.e. ligaments) structures and specificity Functional tests MOVE – Assess Range of • Assess functional Motion movements (i.e. weight bearing activity) Always check Neurovascular Status

Other physical exam Case - Knee Swelling 22 year old Skier comes has twisting • Alignment injury in her knee • Motor strength skiing. Develops • Flexibility of agonists immediate swelling and antagonists after injury and has to be brought down • Neurologic by ski patrol • Check the joint above and the joint below • THINK KINETIC CHAIN

5 Look (Standing) Look (Supine)

• Alignment “SEADS” • Ankles together • Swelling • Ankles apart • Erythema • On toes • Atrophy •Walk • Deformity • Red flag – can’t do it • Surgical scars • Hop test

Feel Feel Patella • Bulge sign • “Milk medially, push • Tender over facets laterally” of patella • Apprehension sign • (Patellar tap) suggests possible instability

6 Feel - Patellar mobility Feel Joint Line

Special Tests ACL Special Tests ACL

• Lachman's test – test at • Lachman's test – test at 20° 20° Sens 81.8%, Spec 96.8% Sens 81.8%, Spec 96.8% • Anterior drawer – test at • Anterior drawer – test at 90° 90° Sens 22 - 41%, Spec 97%* Sens 22 - 41%, Spec 97%* • Pivot shift • Pivot shift Sens 35 - 98.4%*, Spec 98%* Sens 35 - 98.4%*, Spec 98%*

Malanga GA, Nadler SF. Malanga GA, Nadler SF. Musculoskeletal Physical Musculoskeletal Physical Examination, Mosby, 2006 Examination, Mosby, 2006 * - denotes under anesthesia * - denotes under anesthesia Drop Lachman test

7 Medial Collateral Ligament (MCL) Medial Collateral Ligament (MCL) Injury Injury Physical Exam Physical Exam • Tender medially over • Tender medially over MCL (often MCL (often proximally) proximally) • May lack ROM “pseudolocking” • May lack ROM • Valgus stress test – test “pseudolocking” at 20° • Valgus stress test Sens = 86 - 96 %

Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006

Posterior Cruciate Ligament (PCL) Posterior Cruciate Ligament (PCL) Injury Injury Mechanism Symptoms Physical Exam • Sag sign • Fall directly on knee • Pain with activities with foot plantarflexed • “Disability” > Sens 79%, Spec 100% • “Dashboard injury” “Instability” • Posterior drawer test

Sens 90%, Spec 99%

Rubenstein et al., Am J Sports Med, 1994; 22: 550-557

X-ray- often non-diagnostic

MRI is test of choice

8 Special Tests: Meniscus Meniscus Tear Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186. Mechanism Symptoms Test Sensitivity Specificity

• Occurs after twisting •Catching Joint line tender 85.5% 29.4% injury or deep squat • Medial or lateral knee Hyperflexion 50% 68.2% • Patient may not recall pain specific injury • Usually posterior Extension block 84.7% 43.75% aspects of joint line McMurray Classic 28.75% 95.3% • Swelling (Med Thud) McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5% 80%

Modified McMurray Testing Thessaly Test

• Flex hip to 90 • Hold patient’s hands for degrees support ° • Flex knee • Patient bends knee to 5 while he/she twists on knee • Internally or externally • Twisting movement will rotate lower leg with reproduce pain from rotation of knee meniscal injury • Fully flex the knee • Repeat with 20° knee with rotations flexion Medial side: Sens 89%, Spec 97% Lateral side: Sens. 92%; Spec 96%

Karachalios et al. J Bone Joint Surg Am, 2005; 87: 955-962 Courtesy of Keegan Duchicella MD Courtesy of Keegan Duchicella MD

9 Ankle Injury Physical Exam

40 y.o. Male Tennis Symptoms LOOK player suffers • Localized pain usually • Swelling/bruising inversion injury to the over the lateral aspect laterally ankle FEEL Anterior of the ankle talofibular • Difficulty weight • Point of maximal ligament bearing, limping tenderness usually ATF Calcaneo • May feel unstable in MOVE fibular the ankle ligament • Limited motion due to swelling

Special Tests Anterior Drawer Special Tests Anterior Drawer Test Test • Normal ~ 3 mm • Normal ~ 3 mm • Foot in neutral • Foot in neutral position position • Fix tibia • Fix tibia • Draw calcaneus • Draw calcaneus forward forward • Tests ATF ligament • Tests ATF ligament Sens = 80% Sens = 80% Spec = 74% Spec = 74% PPV = 91% PPV = 91%

NPV = 52% van Dijk et al. J Bone Joint NPV = 52% van Dijk et al. J Bone Joint Surg-Br, 1996; 78B: 958-962 Surg-Br, 1996; 78B: 958-962

10 Subtalar Tilt Test Subtalar Tilt test

• Foot in neutral position • Fix tibia • Invert or tilt calcaneus •Tests Calcaneofibular ligament

No Sens / Spec Data

Grading Ankle Sprains Ottawa Ankle Rules

Grade Drawer/Tilt Pathology Functional • Inability to weight bear Test results Recovery immediately and in the in weeks emergency/ office (4 steps) 1 Drawer and Mild stretch 2 – 4 tilt negative, with no • Bone tenderness at the posterior but tender instability edge of the medial or lateral Sens = 97% malleolus (Obtain Ankle Series) 2 Drawer lax, ATFL torn, CFL 4 – 6 Spec = 31-63% tilt with good and PTFL • Bone tenderness over the PPV = 20% end point intact navicular or base of the fifth metatarsal (Obtain Foot Series) NPV = 99% 3 Drawer and ATFL and CFL 6 – 12

tilt lax injured/torn Am J Emerg Med 1998; 16: 564-67

11 “High Ankle” Sprains External Rotation Stress Test

Mechanism • Fix tibia • Dorsiflexion, eversion • Foot in neutral injury • Dorsiflex and • Disruption of the externally Syndesmotic ligaments rotate ankle • Most commonly the anterior tibiofibular ligament No Sens/ Spec Data • R/O Proximal fibular Kappa = 0.75 fracture

Alonso et al. J Orthop Sports Phys Ther, 1998; 27: 276-284

External Rotation Stress Test Squeeze test

•Fix tibia • Hold leg at mid calf • Foot in neutral level • Dorsiflex and • Squeeze tibia and externally fibula together rotate ankle • Pain located over anterior tibiofibular ligament area No Sens/ Spec Data Kappa = 0.75 No Sens/ Spec Data Kappa = 0.50

Alonso et al. J Orthop Sports Phys Alonso et al. J Orthop Sports Phys Ther, 1998; 27: 276-284 Ther, 1998; 27: 276-284

12 Achilles Tendinopathy 3 Basic P/E findings for tendinopathy 28 y.o. Female track athlete has pain in back of calf running 1. Tenderness on direct palpation • Pushing off, running, sprinting, jumping 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch • “Hit in back of leg” while sprinting Exam - Thompson’s test Sens = 96 % • Squeeze calf Spec = 93 % • Foot should plantarflex Maffuli N. Am J Sport Med, 1998; 26: 266-270

Shoulder Impingement Syndrome Impingement Symptoms Problems with: Mechanism • Overhead activities? • Impingement under • Sleep? acromion with flexion • Putting on a jacket? and internal rotation of the shoulder • Rotator cuff, subacromial bursa and biceps tendon

13 Shoulder Pain Differential Diagnosis LOOK • Rotator cuff tendinopathy “SEADS” • Rotator cuff tears • SLAP Lesion • Swelling • Calcific tendinopathy • Erythema • “Frozen” shoulder (adhesive capsulitis) • Atrophy • Acromioclavicular joint problems • Deformity • Scapular weakness • Surgical Scars • Cervical radiculopathy

Winging MOVE – Range of Motion

• Long Thoracic Nerve • What should we measure? – Serratus Anterior –Flexion • Less common – Spinal Accessory Nerve –External rotation (trapezius) – Dorsal Scapular Nerve (rhomboids) –Internal rotation • Scapular Dyskinesis – MOST COMMON • Active vs. Passive – Pain may alter mechanics or vice versa

14 Shoulder Impingement Syndrome MOVE

50 year old woman Left- handed • Has 3 month history of worsening pain in the Left Shoulder • Doesn’t remember any history of pain. • Has difficulty lifting arm and reaching behind her • Sleeping is uncomfortable Painful Arc 60 - 120° Flexion and External rotation

MOVE Rotator Cuff strength testing

Supraspinatus •Empty can • Thumbs down abducted to 90º • Horizontally adduct to 30º For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % Naredo et al. Ann Rheum Dis, External rotation Internal rotation Spec = 100 % 2002; 61: 132-136.

15 Rotator Cuff strength testing Rotator Cuff strength testing

Infraspinatus/teres minor - Subscapularis – Internal External rotation rotation / Lift-off test • Keep elbows at 90º • Patte’s test at 90º For lesions, shoulder abduction Sens = 50 % For tendonitis, Spec = 84 % Sens = 57 % For tears, Spec = 71 % Sens = 50 % For tears, Spec = 95 % Sens = 36 % Spec = 95 %

Naredo et al. Ann Rheum Dis, Naredo et al. Ann Rheum Dis, 2002; 61: 132-136. 2002; 61: 132-136.

Impingement Signs Impingement Signs

Neer Hawkin’s test • Passive full flexion • Flex shoulder to 90º • Positive is • Flex elbow to 90º reproduction of • Internally rotate shoulder pain • Positive - reproduce Sens = 83 % shoulder pain Spec = 51 % Sens = 88 % PPV = 40 % Spec = 43 % NPV = 89 % PPV = 38 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301. NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

16 Impingement Signs Stability Tests

• Spurling’s test for Apprehension test - cervical radiculopathy caution if acute dislocation Sens = 64% • Abduct shoulder to 90° Spec = 95% • Externally rotate arm PPV = 58% NPV = 96% Sens = 69 % Spec = 50 % For labral tear Rowe CR, Zarins B. J Bone Joint surg Am, 1981; 63: 863-872.

Stability Tests Stability Tests Sulcus sign (MDI) Apprehension test - caution if acute No Sens / Spec dislocation Data • Abduct shoulder to 90° • Externally rotate arm

Sens = 69 % Spec = 50 % For labral tear Rowe CR, Zarins B. J Bone Joint surg Am, 1981; 63: 863-872.

17 Labral Test (O’Brien Test) Rotator Cuff Tear vs Impingement? Step 1: Palm Down Step 2: Palm Up • Difficulty lifting – Pain vs weakness ? • Drop arm sign • Fail conservative Tx • Tears uncommon < 40 y.o.

Sens = 10 % For labral tear, + pain For AC joint pathology, + PPV = 100 % deep in shoulder pain over AC joint Bryant et al. J Shoulder Elbow Sens = 67-69 % Sens = 100 % Surg, 2002; 11: 219-224. Spec = 41-50 % Spec = 97 %

9th UCSF Primary Care Sports Medicine Conference: ABC’s of Musculoskeletal Care December 5‐6, 2014 San Francisco, California

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