Disclosures ESSENTIALS OF PRIMARY CARE: A Core Curriculum for - - PowerPoint PPT Presentation

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ESSENTIALS OF PRIMARY CARE: A Core Curriculum for Ambulatory Practice

August 7-12, 2016

Developing a Routine:

Learning a Systematic Evaluation of the Knee, Shoulder and Ankle

Cindy J. Chang M.D.

UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine

Disclosures

I have nothing to disclose

Objective

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Perform an effective problem-focused history and physical examination for evaluation and treatment of musculoskeletal complaints involving the knee, shoulder, and ankle

Important Points

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With a good history…you should arrive at the correct diagnosis 90% of the time

• Or at least a confident top 3 differential!

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With a good history, and comfortable knowledge of basic anatomy…it will make your exam focused, quick and efficient

u And give you more time to chart…

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With a good history, and comfortable knowledge of basic anatomy, you will not need to palpate until the END of the exam…

u Or you risk your patient not letting you finish the

exam!

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Exam Room Tips

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Stock gowns/sheets and paper shorts in the room

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Be able to get to both sides of the exam table

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Always have 2 pillows

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Have a step stool handy

Knee - History

1.

Age

2.

Date of injury/sx onset

3.

Injury Mechanism:

a.

Acute: pop, ability to continue activity

b.

Chronic/Overuse: precipitating activity

4.

Swelling: location and timing

5.

Symptoms: Mechanical

a.

locking, clicking, instability, grinding, weakness

6.

Symptoms: Pain

a.

Location - Point to where it is

b.

Radiation - come from or go anywhere else

c.

Type - burning, sharp, dull, achy, constant, at night, w/ activity or position

7.

Modifying Factors

a.

Better/worse, previous injury or surgery

Medial Knee Lateral Knee

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Anterior Knee Pain Knee – Posterior Knee – A systematic exam

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Observation: effusion, swelling, abrasions, scars

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Sitting: check effusion, knee extension

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Ligament testing:

u Lachman’s (ACL) u Varus/valgus stress testing (MCL/LCL) u Post drawer (PCL)

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ROM

u Popliteal angle (hamstring)/SLR u Hip and knee u Fig 4 – palpate LCL

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Meniscus

u Palpate joint lines, med/lat condyles, check effusion u McMurray's test u Bounce test

Knee – A systematic exam

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Patella

u patellar apprehension test u Palpation of medial/lateral patellar facets/plica/MPFL u patellar tendon and tibial tuberosity u patellar compression test

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Special Tests:

u Nobles test u Thomas test u Sidelying abduction testing/Ober u Apleys test/Thessaly test u Single leg balance/squat

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Stance/Foot type

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Gait

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NVI distally

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Ankle - History

1.

Age

2.

Date of injury/sx onset

3.

Injury Mechanism:

a.

Acute: pop, ability to continue activity

b.

Chronic/Overuse: precipitating activity

4.

Swelling: location and timing

5.

Symptoms: Mechanical

a.

locking, clicking, instability, grinding, weakness

6.

Symptoms: Pain

a.

Location - Point to where it is

b.

Radiation - come from or go anywhere else

c.

Type - burning, sharp, dull, achy, constant, at night, w/ activity or position

7.

Modifying Factors

a.

Better/worse, previous injury or surgery

Ankle Anatomy- Anterior Ankle Anatomy-Lateral Ankle Anatomy-Medial

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Ankle Anatomy-Posterior Ankle – A systematic exam

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Observation: effusion, swelling, ecchymosis

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Squeeze test (fibular head, 5th MT pain)

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Stabiilty/Ligament testing:

u Anterior drawer u Talar tilt: lateral and medial u Talar shift

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ROM

u Ankle:

F Normal: >15° dorsiflexion to >45° Plantarflexion F Slightly decreased: 5-15° DF to 20-45° PF F Significantly Decreased: < 5° DF to <20° PF

u Subtalar:

F 2/3 to 1/3 inversion to eversion (20° to 10°)

Ankle – A systematic exam

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Strength Testing

u DF, PF, Eversion, Inversion u (EHL strength)

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Focal Tenderness

u Medial malleolus, and at level of physis u Medial deltoid ligaments u Lateral malleolus, and at level of physis u Lateral Ligaments:

F ATFL, CFL, PTFL

u Syndesmosis:

F AITFL, PITFL

u Talar dome u Tarsal Tunnel, Post tibialis tendon, Peroneal tendons

Ankle – A systematic exam

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Special Tests:

u Syndesmosis stress test: forced DF/external rotation u Thompson test for Achilles u Calcaneal squeeze test u Slump test to rule out radiculopathy u Bilateral heel raise u Single leg balance/squat

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Stance

u Foot type

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Gait

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NVI distally

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Shoulder - History

1.

Age

2.

Date of injury/sx onset

3.

Injury Mechanism:

a.

Acute: pop, ability to continue activity

b.

Chronic/Overuse: precipitating activity

4.

Swelling: location and timing

5.

Symptoms: Mechanical

a.

locking, clicking, instability, grinding, weakness

6.

Symptoms: Pain

a.

Location - Point to where it is

b.

Radiation - come from or go anywhere else

c.

Type - burning, sharp, dull, achy, constant, at night, w/ activity or position

7.

Modifying Factors

a.

Better/worse, previous injury or surgery

“Arm not fine? First clear the spine!” Shoulder – Ant and Post Shoulder – Superior

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Shoulder – A systematic exam

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C-spine FROM no pain

u Spurling neg

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Observation: Ecchymosis, deformity, atrophy, scars, asymmetry

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ROM comparison (active first, then passive)

u FF, ABD

F Scapular motion

u Horizontal ADD u ER, IR @ 0° and 90° u EXT, IR/ADD (level of vertebrae)

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Strength testing

u Lift-off test, Belly-press test u FF, ABD, Suprapinatus u ER, IR

Shoulder – A systematic exam

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Focal Tenderness

u SC joint, AC joint, clavicle, acromion, subacromial

bursa, coracoid, biceps tendon, supraspinous fossa

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Special Tests

u Instability

F Sulcus sign, Ant-post glide, Posterior shift F Apprehension/Relocation

u Impingement

F Hawkins, Neer's

u Rotator Cuff and Labrum

F Drop Arm, Dropping sign, Hornblower’s sign F Speeds, Yergasons, O'Briens, Biceps Load test n

NVI distally

Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand.

• Chinese proverb