Telemedicine Management of Musculoskeletal Issues Nicole T. Yedlinsky, MD, University of Kansas Medical Center, Kansas City, Kansas Rebecca L. Peebles, DO, Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Nebraska; Uniformed Services University of the Health Sciences, Bethesda, Maryland Telemedicine can provide patients with cost-effective, quality care. The coronavirus disease 2019 pandemic has highlighted the need for alternative methods of delivering health care. Family physi- cians can benefit from using a standardized approach to evaluate and diagnose musculoskeletal issues via telemedicine visits. Previsit planning establishes appropriate use of telemedicine and ensures that the patient and physician have functional telehealth equipment. Specific instructions to patients regard- ing ideal setting, camera angles, body positioning, and attire enhance virtual visits. Physicians can obtain a thorough history and perform a structured musculoskel- etal examination via telemedicine. The use of common household items allows physicians to replicate in-person clinical examination maneuvers. Home care instructions and online rehabilitation resources are available for ini- tial management. Patients should be scheduled for an in-person visit when the diagnosis or management plan is in question. Patients with a possible deformity or neuro- vascular compromise should be referred for urgent evaluation. Follow-up can be done virtually if the patient’s condition is improving as expected. If the condition is worsening or not improving, the patient should have an in-office assessment, with consideration for referral to formal physical therapy or spe- cialty services when appropriate. (Am Fam Physician. 2021;103:online. Copyright © 2021 American Academy of Family Physicians.) Illustration by Jennifer Fairman by Jennifer Illustration Published online January 12, 2021. history collection, virtual physical examination, and initial treatment options. Telemedicine has rapidly become a valuable tool during the coronavirus disease 2019 (COVID-19) Virtual Visit Preparation pandemic.1 Given that musculoskeletal issues are Before the visit, initial preparation includes con- a common reason for primary care visits,2,3 a stan- firming that the patient has functional audio- dardized examination to evaluate these issues via visual resources and providing instructions on telemedicine is useful. Video-assisted orthopedic ideal setting, camera angles, body positioning, consultation for selected patients is cost-effective and attire.6 The physician should review any and does not result in serious adverse events.4,5 previous imaging studies beforehand. Multiple This article discusses telemedicine methods telehealth platforms are compliant with the U.S. and techniques, including visit preparation, Health Insurance Portability and Accountability Act (HIPAA).7 A guide for preparing a medical Additional content at https:// www.aafp.org/afp/ 2021/ 0201/ practice for virtual visits was published previ- 8 CMEp147.html credit. for this article will be available when it is pub- ously in FPM. lishedCME This in print. clinical content conforms to AAFP criteria for Virtual Musculoskeletal Evaluation CME.Author See disclosure: CME Quiz No on relevant page 141. financial affiliations. Author disclosure: No relevant financial affiliations. Patients should be asked about the timing and characteristics of symptom onset, associated Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2021 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2021 American Academy of Family Physicians. For the private, noncom- ◆ 1 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. FebruaryJanuarymercial 12, 1,use 2021 of one Volume Onlineindividual 103, user Number of the website. 3 All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. TELEMEDICINE: MUSCULOSKELETAL ISSUES FIGURE 1 Acromiocla- A B Acromion Clavicle vicular joint Acromion Greater tuberosity Spine of Bicipital the scapula Sternocla- groove vicular joint Shoulder palpation positioning. (A) Anterior view. (B) Posterior view. trauma, location of pain, presence of swell- adhesive capsulitis or severe osteoarthritis.9,13,14 ing, subsequent course, and current status. Patients should also be asked about distal neuro- Functional impact on activities of daily living, vascular symptoms of the upper extremity, such employment, and recreational activities should as weakness or paresthesia. be established. Physicians should ask about pre- The virtual physical examination begins with vious injuries and surgeries, as well as previous inspection. The patient should wear a tank top management and response. or sports bra according to individual comfort. The virtual physical examination should The patient should be asked to face the camera include inspection, palpation, range of motion, and then slowly rotate their body 360 degrees strength, neurovascular assessment, and special so that the physician can observe the shoulder tests.9,10 Although certain maneuvers are difficult joint in all planes. The physician should look to perform virtually, modifications can provide for asymmetry, deformity, abnormal posture, useful information. It may be helpful for the overlying skin changes, atrophy, erythema, and patient to mirror the physician’s motions. ecchymosis. The physician should ask the patient to point SHOULDER to the area of maximal tenderness. The patient For shoulder problems, the physician should ask should be directed to use the contralateral hand if the patient’s primary concern is pain, weakness, to palpate the sternoclavicular joint, clavicle, or decreased range of motion. Pain in the absence acromioclavicular joint, acromion, and spine of of a recent traumatic event often indicates shoul- the scapula, as range of motion allows. Patients der impingement or calcific tendinopathy.11 Pain can also locate and palpate the bicipital groove with cross-arm adduction can indicate acro- and greater tuberosity of the humerus with direc- mioclavicular pathology.9,11,12 Weakness suggests tion from the physician (Figure 1). complete rotator cuff tear or nerve pathology. Shoulder abduction, forward flexion, exten- Decreased range of motion raises suspicion for sion, external rotation, and internal rotation 2 American Family Physician www.aafp.org/afp Volume 103, NumberOnline 3 ◆ JanuaryFebruary 12, 1, 2021 TABLE 1 Telemedicine Assessment of Upper Extremity Range of Motion Plane of range Normal range of active range of motion (Table 111) 11 of motion Patient body positioning* motion (degrees) should be assessed. Alterations of scap- Shoulder ular motion during abduction and Abduction Away from the camera 180 flexion indicate scapular dyskinesia or Extension 90 degrees to the side 45 to 60 weakness of the scapular stabilizing muscles. Flexion 90 degrees to the side for mea- 180 surement, away from the camera Strength testing can be performed for scapular stability by asking the patient to move their Internal Away from the camera for Apley Able to reach shoulder against gravity or by using rotation scratch test vertebral height common household items (Table 2). of T4-T8 Table 3 summarizes suggested rotator 9,11,15 90 degrees to the side, elbow 90 cuff strength tests. Neurovascular abducted to 90 degrees assessment can be completed by hav- External 90 degrees to the side, elbow 90 ing the patient perform a wall push-up rotation at the side so that the physician can look for 90 degrees to the side, elbow 90 scapular winging. Special tests of the abducted to 90 degrees shoulder, such as Speed test to check for proximal biceps tendinopathy and Elbow O’Brien test to detect labral pathology, Flexion Facing the camera, arm 135 to 150 abducted to 90 degrees can be performed using household items as resistance. Extension Same as flexion –10 to 0 Supination Facing the camera, elbow resting 75 to 90 ELBOW on table with arm to the side and elbow flexed to 90 degrees Virtual examination of the elbow begins with inspection of the affected Pronation Same as supination 75 to 90 side and comparison with the unaf- Wrist fected side, looking for erythema, Dorsiflexion 90 degrees to the side 70 deformity, swelling, ecchymosis, and overlying skin changes. The biceps and Palmar flexion Same as dorsiflexion 80 to 90 triceps should be checked for defor- Radial deviation Facing the camera 20 to 30 mity to evaluate for tendon rupture. Ulnar deviation Facing the camera 50 The patient should palpate over the *—Relative to the camera. lateral epicondyle, medial epicondyle, Information from reference 11. and olecranon to check for tenderness (Figure 2). Range of motion assess- ment is reviewed in Table 1.11 Strength of elbow flexion and extension can TABLE 2 be assessed using gravity or common household items (Table 2). Pain that Common Household Items That Can Be Used localizes to the lateral epicondyle with in Telemedicine Strength Testing wrist extension and supination while Item Approximate weight holding a weighted object is suggestive of lateral epicondylitis. Similarly, pain Roll of nickels, cup of sugar, or three C cell batteries 0.5 lb (0.23 kg) that localizes to the medial epicondyle Can of soup, block of butter, or