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Home , Ballottement, Meniscus tear, Range of motion, Shoulder examination

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

• exam • exam Knee Anatomy

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The quadriceps muscles merge to form the The quadriceps quadriceps … patellar tendon muscles extend the knee

http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/Thigh+and +Leg+‐+Lecture+Notes

The flex the knee Pes anserine bursa

www.hep2go.com

http://meded.ucsd.edu/clinicalmed/joints.htm

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There are 4 main in the knee

Musculoskeletal work‐up Knee exam • History • Inspection • • • Other Tests

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Common Causes of by Location of Diagnosis of knee Symptoms

• Anterior: • Medial - Patellofemoral syndrome - Medial -line: or OA - Quadriceps tendinitis - MCL - Patellar tendinitis - Pes anserine bursitis

• Lateral: • Posterior - Lateral jointline: meniscus tear - tendinitis or OA - Gastrocnemius - IT band syndrome - OA, meniscus tears, - LCL sprain (rare) effusion, popliteal cyst…. - Fibular head: fracture (rare)

Altman R et al. 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/.htm

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Palpation of - 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 surgeon for

Permission for use provided by Dr. Charles Goldberg, UCSD Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

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PCL: Posterior Drawer MCL and LCL

MCL and LCL grading 4 tests for meniscus tear

Grade Translation Patient 1. Isolated joint line tenderness compared to response unaffected 2. McMurray side 3. Thessaly I Strain Minimal laxity, Pain 4. 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

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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

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Underlying Anatomy ‐ 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

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The Muscles (SITS) Supraspinatus (Abduction)

The 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 (screwing, twisting) • #2 Flexion of the elbow

Long head 3 attachments: • Radial tuberosity (distal) • Glenoid (long head) • Coracoid (short head) Short head

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Shoulder examination 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 test (rotator cuff dz) • External rotation lag test () • 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

• 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

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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

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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

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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.

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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.

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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%

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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

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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]

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