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Mastering the Musculoskeletal Exam Outline Knee Anatomy

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7/27/2017 Mastering the Musculoskeletal Exam WE HAVE NOTHING UCSF Essentials of Primary Care August 8, 2017 TO DISCLOSE Carlin Senter, M.D. Henry Crevensten, M.D. Outline • Knee exam • Shoulder exam Knee Anatomy 1 7/27/2017 The quadriceps muscles merge to form the The quadriceps quadriceps tendon… patellar tendon muscles extend the knee http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/Thigh+and +Leg+‐+Lecture+Notes The hamstrings flex the knee Pes anserine bursa www.hep2go.com http://meded.ucsd.edu/clinicalmed/joints.htm 2 7/27/2017 There are 4 Meniscus main ligaments in the knee Musculoskeletal work‐up Knee exam • History • Inspection • Palpation • Range of motion • Other Tests 3 7/27/2017 Common Causes of Knee Pain by Location of Diagnosis of knee osteoarthritis Symptoms • Anterior: • Medial - Patellofemoral syndrome - Medial joint-line: meniscus tear or OA - Quadriceps tendinitis - MCL sprain - Patellar tendinitis - Pes anserine bursitis • Lateral: • Posterior - Lateral jointline: meniscus tear - Hamstring tendinitis or OA - Gastrocnemius strain - IT band syndrome - OA, meniscus tears, - LCL sprain (rare) effusion, popliteal cyst…. - Fibular head: fracture (rare) Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039‐49. 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 4 7/27/2017 Palpation of patella - supine Palpation of patellar facet Ballottement 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 Dr. Charles Goldberg, UCSD Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008. 5 7/27/2017 PCL: Posterior Drawer MCL and LCL MCL and LCL grading 4 tests for meniscus tear Grade Injury Translation Patient 1. Isolated joint line tenderness compared to response unaffected 2. McMurray side 3. Thessaly I Strain Minimal laxity, Pain 4. Squat firm endpoint II Partial tear Some laxity, Pain, may feel firm endpoint loose These tests not needed in patients with knee OA. III Complete tear Obvious laxity, Minimal pain, Do these tests in patients < 50 with isolated joint no endpoint may feel very line tenderness. loose 6 7/27/2017 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5th 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 7 7/27/2017 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 8 7/27/2017 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 9 7/27/2017 Shoulder examination Neck examination Key Components of the Special Tests: • Hawkins impingement sign • Shoulder Exam: • Neers impingement sign Inspection ‐ Neck • Painful arc (rotator cuff dz) • Palpate CS ‐ Shoulder • Jobe’s, aka Empty‐can (supraspinatus) ‐ Inspection • Drop arm test (rotator cuff dz) • External rotation lag test (rotator cuff tear) • FF and extension ‐Palpation • Internal rotation lag test (rotator cuff tear) ‐ Range of Motion: • Speeds (biceps) • Spurlings abduction, flexion, ER, IR • Yergason’s (biceps) ‐Strength • O’briens (SLAP tear) • AC crossover (AC joint OA or sprain) ‐Neurovascular Cervical Spine Spurling’s Maneuver Shoulder examination • Neck extended • Inspection • Head rotated toward – Patient in gown affected shoulder • Palpation • Axial load placed on • ROM the cervical spine • Strength • Reproduction of – Supra patient’s – Infra and teres shoulder/arm pain minor indicates possible – Subscapularis nerve root • Other tests http://meded.ucsd.edu/clinicalmed/joints compression 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM 10 7/27/2017 Inspection Shoulder examination • Presence of infraspinatus atrophy increases • Inspection likelihood of rotator cuff disease • Palpation • Positive LR 2.0 • ROM http://meded.ucsd.edu/clinic almed/joints2.htm, • Negative LR 0.61 • Strength permission granted by Dr. – Supraspinatus Charles Goldberg, UCSD SOM – Infraspinatus & Teres minor – Subscapularis • Other tests Litaker D et al, J Am Geriatr Soc, 2000. Range of motion Range of motion Internal rotation Abduction External rotation Flexion 11 7/27/2017 Supine shoulder PROM Passive range of motion • If limited AROM in any direction • Follow up by testing passive motion in that direction • If limited active and passive ROM think – Frozen shoulder – Glenohumeral joint arthritis Shoulder exam practice Shoulder: diagnosis driven exam • Neck: palpation, ROM and Spurling’s maneuver Active ROM • Inspection Normal Decreased • Palpation • AROM Weak = Rotator cuff tear – Abduction Limited by pain = Passive ROM Other rotator cuff dz – Flexion Normal Labral tear – External rotation (ER) Biceps tendinitis Decreased – Internal rotation (IR) AC joint OA Xray GH joint • PROM OA 1 Frozen shoulder Normal Abnormal 12 7/27/2017 Other tests Rotator cuff disease exam • Rotator cuff disease (RCD) • Pain provocation tests • Pain and strength tests – Bursitis or impingement • Often the pain radiates to lateral shoulder/proximal arm (“deltoid”) – Tendinitis/tendinopathy – Partial tear – Full thickness tear • Biceps tendinitis/tendinopathy • Labral tear • AC joint osteoarthritis Pain test: Impingement signs Pain test: Painful arc If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD. Hawkin’s Photos from Dr. Christina Allen Neer’s JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 13 7/27/2017 Exam practice: Pain & Strength test: pain provocation tests in RCD Supraspinatus = abduction • Hawkins impingement sign Supraspinatus • Neers impingement sign • Painful arc (rotator cuff dz) 71% sensitivity 2 41% specificity for Empty can rotator cuff (aka Jobe’s) disease. (+) LR 1.3 Photos from Dr. Christina Allen Physical exam maneuvers that increase Pain/strength test: Drop arm test likelihood of full thickness rotator cuff tear 1. External rotation Positive LR 3.3, lag test negative LR 0.82 for rotator cuff 2. Internal rotation disease. lag test https://www.healthbase.com/hb/images/cm/p rocedures/orthopedics/rotator_cuff_tear.jpg JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 14 7/27/2017 Strength test: Pain & Strength test: External rotation lag test Subscapularis = internal rotation lag test Positive LR 7.2, Negative LR 0.57 Positive LR 5.6, for full thickness negative LR rotator cuff tear 0.04 for full thickness rotator cuff tear JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Exam practice: Biceps Tests: Speeds Rotator cuff strength and tear • Jobe’s, aka Empty‐can (rotator cuff disease) Tests for biceps pathology (tendinitis, tendinopathy, • Drop arm (rotator cuff disease) tear) • External rotation lag test (rotator cuff tear) Palms up, patient pushes • Internal rotation lag test aka Lift‐off test up against resistance (rotator cuff tear) (resisted elbow flexion) +Test is pain at proximal biceps tendon 3 Sens = 54%, Spec = 81% 15 7/27/2017 O’Brien’s Test Biceps Tests: Yergasons To r/o Labral Tear Tests for biceps pathology • Arm forward flexed to 90° (tendinitis, tendinopathy, • Elbow fully extended tear) • Arm adducted 10° to 15° with thumb down Patient supinates (twists • Downward pressure out) against resistance • Repeat with thumb up • Suggestive of labral tear +Test is pain at proximal if more pain with thumb biceps tendon down Also tests for biceps • Sens = 59-94%, strength • Spec = 28-92% Sens = 41%, Spec = 79% Exam practice: Testing the AC Joint: AC Crossover biceps tendinitis, labral tear, AC OA • Speeds (biceps) • Tests for AC joint osteoarthritis or • Yergason’s (biceps) sprain • O’briens (SLAP tear) • Can be done • AC crossover (AC joint OA or sprain) passively by patient or physician • +Test is pain at AC joint 4 16 7/27/2017 Shoulder examination Thank you Key Components of the Special Tests: • Hawkins impingement sign Shoulder Exam: • Neers impingement sign ‐ Neck • Painful arc (rotator cuff dz) ‐ Shoulder • Jobe’s, aka Empty‐can (supraspinatus) ‐ Inspection • Drop arm test (rotator cuff dz) • External rotation lag test (rotator cuff tear) ‐Palpation • Internal rotation lag test (rotator cuff tear) ‐ Range of Motion: • Speeds (biceps) abduction, flexion, ER, IR • Yergason’s (biceps) ‐Strength • O’briens (SLAP tear) • AC crossover (AC joint OA or sprain) ‐Neurovascular Questions? [email protected] 17.
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  • Common Disorders of the Knee

    Common Disorders of the Knee

    7/27/2017 Common Disorders of Disclosures the Knee Carlin Senter, MD I have nothing to disclose. Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics UCSF Essentials of Primary Care August 8, 2017 Knee: Top 3 referral diagnoses from Objectives primary care IM to ortho (at UCSF in 2011) 1. Osteoarthritis (OA) Upon completion of this session, participants should be able to: 2. Anterior knee pain 1. List 4 exam maneuvers for meniscus tear • Patellofemoral pain syndrome 2. List the diagnostic criteria for knee OA • Chondromalacia patella 3. Identify 5 non operative treatment options for knee OA • Patellar tendinopathy 4. Identify indications for surgery for patient with meniscus tear 3. Meniscus tear ‒ Without knee OA ‒ With knee OA 5. Generate a differential diagnosis for chronic anterior knee pain 1 7/27/2017 Case #1 All of the following tests, if positive, would raise concern for a meniscus tear except… 25 y/o man with medial-sided pain and swelling of the R knee for 6 A. Joint line tenderness weeks since he twisted the knee playing soccer. No locking, no instability. B. Pain when he stands and pivots on the knee C. Pain when you axially load and rotate the knee D. Pain when you flex the R knee and extend the R hip with the patient lying on his left side. E. Pain when he squats 4 tests for meniscus tear Joint line tenderness 1. Isolated joint line tenderness 2. McMurray 3. Thessaly 4. Squat Medial: Sensitivity 83%, Specificity 76% Lateral: Sensitivity 68%, Specificity 97% (Konan et al.