Evaluation and Treatment of Common Musculoskeletal Complaints - - PDF document
Evaluation and Treatment of Common Musculoskeletal Complaints Katherine Julian, MD July 2014 No conflicts of interest Outline of Session Joint Anatomy (Knee and Shoulder) Exam Demonstration: HIT ME NOT 1 History Inspect
Joint Anatomy (Knee and Shoulder) Exam Demonstration: HIT ME NOT1
History Inspect Touch Move Extra maneuvers Things to NOT miss
Exam Practice Cases (knee and shoulder)
Neuman WR, Cato RK, Fosnocht KM, O’Rorke. SGIM, 2006
Osteoarthritis Meniscus tear Patellofemoral Pain
Courtesy of Carlin Senter, MD, UCSF
http://www.bigkneepain.com/knee_anatomy.html Patella Tendon Quadriceps Tendon Meniscus
Quadriceps muscles extend the knee Hamstrings flex the knee
http://www.rolfing.com.sg/Hamstring.html Flota.com
MCL: resists valgus
Medial femoral condyle to
medial tibia (crosses medial jointline)
LDL: resists varus
Lateral femoral condyle to
fibular head (crosses lateral jointline)
ACL: resists anterior
PCL: resists posterior
www.straightbackphysio.co.uk
Mechanism of injury? Effusion?
Immediate or delayed
Sounds? Unstable? Locking or catching
“Point to the Pain”
Medial Knee Pain (most
common)
Osteoarthritis Anserine Bursitis Medial Meniscal Injury
Lateral Knee Pain
Lateral Meniscal Injury Osteoarthritis Iliotibial band tendonitis
“Point to the Pain”
Anterior Knee Pain (most common < 45 yrs)
Patellofemoral syndrome Patellar tendonopathy Severe OA Prepatellar bursitis
Posterior Knee Pain
Baker’s Cyst Vascular Sciatica
Symmetry (standing)
Alignment (valgus/varus
stresses)
Atrophy of muscles Swelling vs. effusion
Effusion=intra-articular
joint pathology
Swelling=soft tissue injury,
bursitis, tendonitis
Redness www.bonesmart.org
Temperature
By compartment
Test for Effusion
TAP the PAT
Milk suprapatellar pouch
with downward pressure
Tap patella against femur
(check for “bob”)
Can also feel for effusion
with hand wrapping around the tibia
Traumatic knee effusion
ACL (or ligament) tear Patellar
dislocation/subluxation
Meniscus tear Patellar or quadriceps rupture Fracture Bone contusion Cartilage injury OA exacerbation in OA pt
Atraumatic knee effusion
Meniscus tear OA Crystal arthropathy (gout,
pseudogout)
Inflammatory arthritis Septic joint Benign or malignant tumor
Lying down with knee slightly flexed…
Palpate and move the patella Tendons (two fingers)
Quadriceps Patellar
Tibia (two fingers)
Tuberosity Medial: joint line, MCL, anserine bursa Lateral: joint line, LCL, fibular head, biceps femoris,
iliotibial band
Passive ROM
Extend as far as possible (normal 0 degrees) Flex knee as far as possible (normal 135 degrees)
Active ROM
Resisted flexion and extension at 120 degrees
“Lock” the Knee
Can’t lock---suspicion for meniscal injury (bucket
Patellar assessment
Patellar apprehension test
Knee flexed 45⁰ Fingers at medial patella Try to move patella
laterally
Anterior Cruciate
Anterior Drawer
Knee flexed 90⁰ Foot fixed slight external
rotation
Sens 22-41%, spec 97%
Lachman Test
Knee flexed 30⁰ Stabilize distal femur with
proximal tibia with the other
Sens 75-100%, spec 95-
100%
Compare both sides!
Posterior Cruciate
Posterior sag sign
Knee flexed 90 Look for posterior
displacement of the tibia
Posterior drawer test
Knee flexed 90 Foot fixed in neutral
position
Thumbs at tibial tubercle
Push posteriorly
Collateral ligaments
MCL
Leg slightly abducted Valgus Stress
At full extension (0⁰
degrees).
Repeat at 30⁰ flexion
Why test at flexion and
Laxity only with flexion: isolated
collateral ligament injury
Laxity with both: collateral
ligament injury + possible cruciate ligament injury
Collateral ligaments
LCL
Leg slightly abducted Varus Stress
At full extension (0⁰
degrees).
At 30⁰ flexion
Compare both sides
Isolated joint line tenderness McMurray Thessaly Squat
Menisci
McMurray Test
Medial meniscus
Feel medial joint line Tibia rotated externally Knee extended from
maximal flexion to extension
Add varus stress with
extension
Positive test = thud, click
Menisci
McMurray Test
Lateral meniscus
Feel lateral joint line Tibia rotated internally Knee extended from maximal flexion
to extension
Add valgus stress with extension
Better sensitivity than
Examine both knees Stand on normal first Flex 5⁰ then 20⁰ Positive test=pain at joint
line with possible locking/catching sensation
Karachalios et al. JBJS, 87AL;955‐962.
Effusion Joint Instability
Ligament injury
Red-flags
Night pain Fever Weight Loss Limp Could indicate infection or tumor
History Inspection Touch
Effusion Jointlines Tendons
Move
Passive ROM (extend, flex) Active ROM at 120 degrees Lock the knee
Extra Maneuvers
Patellar apprehension Anterior drawer/Lachman Posterior drawer Valgus stress Varus stress McMurray Thessaly (Squat)
Case One
27 yo man with knee pain X 3 months. Started after
Pain medial side of knee. Worse with
Dx?
Meniscal tear
Menisci provide cushion between tibia and femur History: twisting injury to knee with foot in weight-
Popping or tearing sensation Pain medial or lateral Locking may occur Slow effusion; if no effusion, consider alternate dx
Exam?
Joint line tenderness Long-standing dz, may see quadriceps atrophy May see positive McMurray or Thessaly test
Treatment
RICE X 2-6 weeks
Rest→crutches Ice Compression→bulky compression dsg from mid-thigh to mid-
calf
Elevation Exercise: quad strengthening with gentle ROM in 2-3 days
Refer if no better 2-6 weeks
May need surgery
Concern for bucket-handle injury→referral
Case Two
18 yo woman with knee pain X 1 month Pain anterior knee. Hurts to walk and go up stairs.
Dx?
Patellofemoral Pain Syndrome
Cause unknown Pain over anterior aspect of knee in absence of
Any injury/anatomic abnormality that
Symptoms
Pain beneath/near patella Pain with squatting/prolonged sitting Pain with single leg knee dip
Treatment
Reassurance No or limited bent-knee activities. Avoid stairs. Straight leg raises to prevent atrophy Quad stretching twice/day. One minute. NSAIDS, ice, heat May take 3 months to improve If not better, consider PT, re-examine (check Dx)
Case Three
60 yo woman with six
months of knee pain
Pain medial aspect of
with am stiffness.
Dx? DJD
Are symptoms from meniscus
All patients with arthritis have meniscal tears X-ray
Standing AP both knees, both laterals and
If normal X-ray→meniscal
Case Four
37 yo woman with knee injury 2 years ago with knee
Was playing tag football and was “clipped”. Knee
Dx? Ligament tear (likely ACL)
Mechanism: Forceful stress against knee when
Valgus stress: MCL Varus stress: LCL Twisting injury (pop): ACL
Collateral (except complete LCL)
RICE, early rehab Can use functional hinged braces Complete tear of LCL→surgery to prevent
Isolated cruciate injuries
Attempt at non-surgical treatment unless high
Chronic instability
Most often from ACL deficiency, deterioration Usually not painful (unless torn meniscus) Treatment depends on degree of instability and how
PT
Hamstring strengthening
Case Five
45 yo man c/o pain in the
posterior knee. Now
posterior knee swollen with mass lateral to the medial hamstrings in the popliteal fossa
Dx? Baker’s Cyst
Enlargement of popliteal cyst (semimembranous
Typically secondary to intra-articular pathology
Chronic effusion communicates from joint to cyst
Treat primary (underlying) abnormality Can aspirate and inject with steroids if needed…
Case Six
45 yo woman c/o anterior
knee pain. Started gardening this spring. Knee is painful and red.
Dx? Prepatellar bursitis
Pre-patellar bursa lies between the skin and
Acute Trauma→bloody Atraumatic (friction, kneeling) If red, aspirate it BUT NOT THE JOINT. If not
Treatment: avoid friction, NSAIDS, time,
Rotator cuff disease
Subacromial bursitis Tendinitis or tendinopathy Partial tear Full thickness tear
Frozen shoulder (adhesive capsulitis) Glenohumeral joint osteoarthritis
Courtesy of Carlin Senter, MD, UCSF
Three bones
Scapula Clavicle Humerus
4 Articulations
Glenohumeral Scapulothoracic Acromioclavicular Sternoclavicular
Supraspinatus
Abduction
Infraspinatus
External rotation
Teres Minor
External rotation (adduction)
Subscapularis
Internal rotation Adduction
Inflammation of the
Under the acromion and
above the glenohumeral joint
Structures=supraspinatus,
subacromial bursa
Sx: hurts with reaching,
Exam Demonstration: HIT ME NOT
History Inspect Touch Move Extra maneuvers Things to NOT miss
Hand dominance Occupation/hobbies (Lifting? Overhead activities?) History of dislocation or recent injury? What hurts? Where does it hurt?
Pain that radiates past elbow---consider cervical spine Don’t forget conditions that cause radiation of pain into
ROM limitation?
Examine with both shoulders widely exposed
Contour
Symmetry Dislocation Fracture
Atrophy (anterior AND posterior)
Infraspinatous atrophy increases LR of rotator cuff disease
Swelling
Difficult to assess
Temperature 3 Places to Touch
Acromioclavicular joint Subacromial space Biceps tendon
Check both sides
Some sites tender even if
normal shoulder
Active ROM
Forward Flexion Extension Abduction Internal Rotation (reach backwards behind shoulder
External Rotation (elbows at sides or hands behind
Compare both sides!
If full ROM actively, no need to test passive
If loss of both active and passive ROM??
2 things to consider
Adhesive capsulitis Severe OA of glenohumeral joint X-ray will help you differentiate
Supine Passive ROM
Outward motion=external
rotation
Inward motion=internal
rotation
Impingement tests Rotator cuff tests Biceps tests Labral tears AC joint: crossover
Forward flex arm to 90⁰
Arm then internally
Positive test =
“Near the ear”
Thumb down Forward flexion of arm to
180 degrees
RCD can include:
Rotator cuff muscle
tendinopathy (1 or more
muscles)
Full tear Partial tear Subacromial bursitis
Pain provocation tests Pain and strength tests
Hermans J, et al. The rational clinical examination: does this patient with shoulder pain have rotator cuff disease? JAMA, 2013;310(8).
If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD
Arm passively raised to 160⁰ Pt asked to slowly lower arm
to the side
Positive test = inability to
control lowering and dropping
Dx = large rotator cuff tear
Hermans J, et al. The rational clinical examination: does this patient with shoulder pain have rotator cuff disease? JAMA, 2013;310(8).
Positive LR 3.3 for rotator cuff disease
Pain and strength test Tests supraspinatus
Arms abducted 90⁰ and
Thumbs downward Resist downward force
Pain and strength test Tests infraspinatus and
Pts arms held at their
Patient pushes externally
Pain and strength test Tests subscapularis Arm internally rotated behind
back
Hand is lifted off back and pt
must maintain position
Alternate: bear hug to
Hermans J, et al. The rational clinical examination: does this patient with shoulder pain have rotator cuff disease? JAMA, 2013;310(8).
Positive LR 5.6 for full thickness rotator cuff tear. Negative LR 0.04
Strength test Tests supraspinatus and
infraspinatus
Examiner passively rotates the
pt’s arm into full external rotation
Positive=pt unable to maintain
full external rotation
Hermans J, et al. The rational clinical examination: does this patient with shoulder pain have rotator cuff disease? JAMA, 2013;310(8).
Positive LR 7.2 for full thickness rotator cuff tear
Test for biceps pathology
Palms up, patient pushes
Positive = pain at
Sens 54% spec 81%
Test for biceps pathology
Pt supinates (twists out)
“Turn a door knob” Positive = pain at
Sens 41% spec 79%
Arm forward flexed to 90° Elbow fully extended Arm adducted 10° to 15°
with thumb down
Downward pressure Repeat with thumb up Suggestive of labral tear if
more pain with thumb down
Sens 59-94%; spec 28-92%
Young athletes from acute trauma, weight lifters Clicking or catching SLAP = superior labrum anterior-posterior is typical
MRI vs. MR arthrogram Tx conservative management (PT, injection, time);
Pts > 50 yrs labrum degenerates, not a source of pain
Arm crosses over body Can be done passively by
Tests for AC joint OA or
Positive = pain at AC
Referred pain!
Cardiac Abdomen (subdiaphragmatic) Pulmonary (Pancoast tumor) Radicular
Always examine the neck
Inspection, palpation of
Spurling’s
Neck extended Head rotated towards
affected shoulder
Axial load placed Reproduction of
shoulder/arm pain = possible nerve root compression
Inspect Touch
AC joint Subacromial space Biceps tendon
Move
Active (flexion, extension,
abduction, internal/ext rotation)
Painful arc? Passive if needed
Neck Exam
Spurling’s
Extra maneuvers
Hawkin’s Impingement Neer’s Rotator cuff tests
Drop arm Empty can External rotation Lift off External rotation lag
Crossover maneuver
Who Needs an X-Ray?
Chronic shoulder pain No improvement after treatment Odd hx or PE, history of trauma
Standard plain radiographic series for the
Anteriorposterior Axillary (i.e. lateral) Scapular Y view
Assesses shape of acromion Helps to determine humeral head dislocation
Why get X-rays?
Can determine DJD of AC and glenohumeral joint Large rotator cuff tear = superior migration of
Calcific tendinitis
MRI
Rotator cuff tears
Case One
65 yo woman with h/o overuse shoulder injury after
On exam, limited active ROM and passive ROM DDx
Adhesive capsulitis Glenohumeral joint OA
What test to do next?
X-ray
Insidious onset of pain and restriction of motion
Pain usually AFTER significant loss of motion Pain usually localized to rotator cuff; may radiate
Interferes with sleep
More common in women and diabetics Cause unknown, but can be post-traumatic
Examination
Deltoid and/or supraspinatus atrophy Tenderness around rotator cuff and biceps tendon Active and passive ROM restricted Best Dx test: no passive external rotation DDx: glenohumeral joint infection vs. DJD Treatment
Prevention! Injection ROM exercises (hourly!)
Red, angry-looking shoulder
= septic arthritis of AC joint
Aspirate, labs, X-Ray, refer
Glenohumeral joint infection
Rare Shoulder looks normal, just
bigger
SEVERE pain with any
motion
Often a fever More in diabetics,
immunocompromised
Rare
Seen as secondary process
RA, avascular necrosis, chronic rotator cuff disease Overuse of shoulder (ex: baseball pitchers)
Age > 50 yrs Chronic pain, limited motion May see atrophy and crepitus Dx: X-ray Treatment: injection, NSAIDS, stretching
Case Two
50 yo woman c/o pain in lateral aspect of arm.
+painful arc, +Neers/Hawkins, +pain with empty
DDx?
Risk factors for degeneration of the rotator cuff
Age (tears rare <40) Impairment of cuff vascularity Repetitive microtrauma External abnormalities that narrow the subacromial
Osteophytes Shape of acromion
With time, overlying bursa and tendons affected
Impingement
Friction Overuse Bursitis→tendonitis→rotator cuff tear
Bursitis = pain but not when testing cuff Tendonitis = hurts when cuff muscles are tested Rotator cuff tear = weakness (often without pain)
Impingement/Bursitis
History: pain with overhead activity
Lateral shoulder (may radiate to deltoid) Often night pain Can’t lie on shoulder
May have tenderness over supraspinatus insertion
If rotator cuff weakness present→order x-rays
Full thickness tear→refer to ortho Better surgical outcomes if full thickness tears fixed
Less muscle atrophy and retraction
Treatment
Partial/small tears
Treat like tendonitis
Some will require surgical treatment
Based on pain, age, activity level, degree of tear
Impingement Treatment
Activity modification
No activity with elbow away from side
Once daily, fully stretch overhead NSAID, ice Injection 3-6 weeks PRN PT AFTER pain subsides
Regain ROM and strengthen rotator cuff
Case Three
40 yo man playing flag football over the last year
+TTP biceps tendon, +Speeds, +Yergason’s DDx?
Inflammation of biceps
May be primary disorder
Can be difficult to
differentiate from rotator cuff disorders
Usually occurs without
Result of advanced
Sudden onset Sharp snap, pain, arm
Usually, no treatment