[PDF] - Knee Physical Exam and Disclosures: None Injection Skills Carlin PDF Document

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Knee Physical Exam and Injection Skills

UCSF Essentials of Women’s Health 7/2/19

Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics Henry Crevensten, MD Associate Professor of Medicine, UCSF Deputy Director Primary Care San Francisco VA Health Care System

Presentation Title 2

Disclosures: None Knee Anatomy 2 tendons 4 bones 3 articular surfaces 4 ligaments 2 menisci

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3 articular surfaces

Articular cartilage

4 ligaments

MCL LCL ACL PCL

2 menisci (or meniscuses)

Medial and lateral
Shock absorber
Stabilizer

Musculoskeletal work-up

History
Inspection
Palpation
Range of motion
Other Tests

SLIDE 3

Most common knee problems in US adults

Patellofemoral pain syndrome (PFPS) Meniscus tear OA Age Younger Young- middle age Older or h/o trauma Activity Overuse injury Acute or degenerative Acute or overuse Swelling Soft tissue (no effusion) +/- effusion +/- effusion Locking May endorse but usually crepitus If bucket handle tear May endorse but usually crepitus Instability Pain may lead to this

esp. down hills/ stairs

Not usually Preceded by pain

If torsional instability think ligament tear.

Common causes of knee pain by location of symptoms

Anterior
Patellofemoral syndrome
Quadriceps tendinitis
Patellar tendinitis
Patellar / quad tendon tear
Lateral
Joint line: meniscus tear or OA
IT band syndrome
LCL sprain (rare)
Medial
Joint line: meniscus tear or OA
MCL sprain
Pes anserine bursitis
Posterior
Hamstring tendinitis
Gastrocnemius strain
Meniscal root tear
OA, meniscus tears, effusion,

popliteal cyst….

The essential knee exam The essential knee exam

To identify patellofemoral pain, OA and meniscus tears

Standing: Inspection (varus, valgus or neutral)
Seated
Palpation of joint lines (and in doing so palpating distal femur, proximal tibia)
Examine for quad atrophy (by having patient straighten legs, compare side to side)
Supine
Palpation of patellar facets
Evaluate for effusion
Range of motion: flexion, extension
McMurray test (meniscus)
Standing: Squat and Thessaly tests (meniscus)

Bonus maneuvers - supine 1. Lachman (ACL) 2. Valgus stress (MCL) 3. Varus stress (LCL) 4. Posterior drawer (PCL)

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Standing: Inspection

http://doctorhoang.wordpress.com/ 2010/09/06/valgus-knee-and- bunion/ http://www.kneereplacementlondon.com/patient- information/osteotomy

Seated: Joint line tenderness (JLT)

Medial: Sensitivity 83%, Specificity 76% Lateral: Sensitivity 68%, Specificity 97%

Medial joint line Lateral joint line Femur Tibia Patella Fibula

Konan et al. Knee Surg Traumatol Arthrosc. 2009

Supine: Palpation of patellar facets

Video courtesy of Dr. Anthony Luke

Effusion

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Knee range of motion

ROM: normal 0-135
Determine if knee is locking or if

ROM is limited due to effusion and/or pain/guarding/stiffness

Locking: think bucket handle

meniscus.

Urgent xrays, MRI
Urgent referral to sports

surgeon for arthroscopy

Meniscus: McMurray test

Sensitivity medial 65%, Specificity medial 93%

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

T est for meniscus: Internally rotate the tibia and extend  lateral meniscus Externally rotate the tibia and extend  medial meniscus Pain and / or snap/click at the joint line = concerning for meniscus tear

Video courtesy of Dr. Anthony Luke

Composite exam: JLT + McMurray

JLT more sensitive than McMurray for meniscus tear
McMurray more specific than JLT for meniscus tear
Joint line tenderness LR 0.9 for positive exam
McMurray LR 1.3 for positive exam
Composite assessment LR 2.7 for positive exam

Solomon DH et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? JAMA. 2001 Oct 3;286(13):1610-20.

Lachman test for ACL

Sensitivity 75-100%, specificity 95-100%

This is a negative Lachman test: there is an endpoint to the anterior tibial translation.

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

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Positive Lachman Valgus stress for MCL and Varus stress for LCL

This is a normal exam (no pathologic laxity).

Video courtesy of Drs. Kalli Hose and Anna Quan

Posterior drawer for PCL Standing: Meniscus: squat

Patient stands flat-footed
Examiner holds their hands

for balance

Patient squats as low as

possible

(+) If pain or feeling of

locking while knees bent

Sensitivity 75-77%, Specificity 36-42%

Snoeker BAM et al. J Orthop Sports Phys Ther. 2015 Sep;45(9):693-702.

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Standing: Meniscus: Thessaly test

If medial pain when pivot medially then concern for medial meniscus tear; if lateral pain when pivot laterally then concern for lateral meniscus tear.

Video courtesy of Dr. Anthony Luke

How to do a Knee Injection

Carlin Senter, MD Associate Professor Primary Care Sports Medicine University of California San Francisco

Watch: How to do a Knee Injection Video

https://binged.it/2QCSWcw

Indications for knee aspiration/injection

Diagnostic
Effusion, esp atraumatic
Send for cell count, differential, crystals +/- gram stain and culture
Therapeutic
Osteoarthritis
Crystal arthropathy
Inflammatory arthritis

SLIDE 8

Intra-articular corticosteroid injections: benefits

Short-term pain relief (6 weeks average)
Small effect on function
No evidence for long-term pain relief
Clinical effect independent of degree of inflammation present
Don’t need to restrict injection just to those with effusion
Frequency: general practice once every 3-4 months max
Concern for cartilage toxicity if given q 3 months x 2 years

Contraindications to steroid injection

Joint infection
Hemarthrosis
Overlying cellulitis
Fracture
Prosthetic joint

Relative contraindications to steroid injection

Corticosteroid injection within past 3-4 months
Coagulopathy
Poorly controlled diabetes

Risks of steroid injection in the knee

Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days
Facial flushing: 10% with Kenalog
19-36 hours post-injection
Skin or fat atrophy
Post-injection steroid flare: 1-10%
Synovitis in response to injected crystals
Within hours - 48 hours post-injection
More common in soft tissue injections (20% of trigger points) than intra-articular injections
Septic arthritis: 1/3000-1/50,000
1-2 days after injection

Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2010.

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Why aspirate the effusion before injection?

Clinically
Decreased pain and stiffness because effusion gone
More effect of steroid because not diluted by effusion
Inspect fluid for inflammation/infection, send to lab if question
Confirms that injxn was intra-articular
Significantly greater improvement in VAS for patients who had joint aspirated at time
f injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.)
Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann

Rheum Dis, 2000.)

Aspiration/injection supplies

Betadine swab x 3
Ethyl chloride spray
Alcohol swabs x 6
4x4 gauze x 1
Bandaid x 1

Needles, syringes, meds Aspiration

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Superolateral approach

Patient supine
Extend knee
Bump under knee so flexed 10-20

degrees

Superior border patella
Lateral border patella
1cm below
Mark with syringe cover or tip of pen

Post-injection patient instructions

Rest: no definitive evidence-based recommendation
Recommendations in literature vary
No restrictions
Bed rest x 24 hours
Light activity x 7 days, no weight bearing exercise
I recommend no strenuous activity x 7 days
Avoid swimming, hot tub, bath x 24 hours
Let injection site heal

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UCSF CME: Essentials of Women’s Health July 2019 The Essential Physical Exam of the Knee for the Primary Care Clinician

Maneuver Notes

Standing  Inspection (knees varus, valgus, neutral, feet pronated or supinated) Supine  Palpate patellar facets  Evaluate for effusion  Range of motion (flexion, extension)  McMurray’s test (meniscus) Supine or Seated: bonus maneuvers  Valgus stress for MCL at 0 and 30 degrees  Varus stress for LCL at 0 and 30 degrees  Lachman test for ACL  Posterior drawer for PCL Standing  Squat (meniscus)  Thessaly (meniscus)

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Shoulder Physical Exam and Injection Skills

UCSF Essentials of Women’s Health 7/2/19

Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics Henry Crevensten, MD Associate Professor of Medicine, UCSF Deputy Director Primary Care San Francisco VA Health Care System

Presentation Title 2

Disclosures: None Shoulder anatomy

3 bones:

clavicle
scapula
humerus

4 joints:

acromioclavicular
glenohumeral
scapulothoracic
sternoclavicular

Shoulder bony anatomy

Slide adapted with permission from Drs. Meg Pearson and Steve Bent Humerus Scapula AC joint Glenohumeral joint Clavicle SC joint

SLIDE 13

Rotator cuff anatomy

Supraspinatus: Abduction
Infraspinatus: ER
Teres Minor: ER
Subscapularis: IR

Anterior Posterior Infraspinatus Subscapularis Supraspinatus Teres minor

Shoulder Glenohumeral Stabilizers: Labrum

Labrum

Slide used with permission from Drs. Anna Quan and Kalli Hose

Shoulder Glenohumeral Stabilizers: Capsule

Prevents anterior, inferior and posterior displacement

Slide used with permission from Drs. Anna Quan and Kalli Hose

Most common shoulder problems in US adults

Impingement Labral tear Rotator cuff tear Adhesive capsulitis Glenohumeral joint OA Age < 40 < 40 ish > 40 40-60 y/o > 60 y/o Mechanism Overuse Overuse or acute Overuse or acute Acute

nset

without MOI +/- diabetes +/- distant h/o trauma Location of pain Lateral shoulder Deep - Anterior shoulder Lateral shoulder Generaliz ed Generalized Stiffness No No No Yes Yes

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Musculoskeletal work-up

History
Inspection
Palpation
Range of motion
Other Tests

Shoulder exam The essential shoulder exam

Inspection - infraspinatus atrophy, skin findings
Palpation of AC joint, long head biceps tendon
Active range of motion: abduction, forward flexion, external rotation,

internal rotation

Passive range of motion: abduction to 90, external rotation at 90,

internal rotation at 90

Impingement: Hawkins test, Neers test
Strength: Empty can test, Belly press test, Resisted external rotation

Inspection

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Palpation: AC joint, Biceps tendon Active range of motion

1. Forward flexion
2. Abduction
3. External

rotation

4. Internal rotation

Passive range of motion

1. Abduction

(glenohumeral joint allows abduction from 0 -90°; the rest

f abduction is due

to scapulothoracic motion)

2. External rotation
3. Internal rotation

Impingement: Neer’s test

Neer’s test (Neer by

the ear)

Passive
Arm pronated and

forward flexed

Pain indicates

subacromial impingement

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Impingement: Hawkins test

Hawkin’s test (Flap arm like a bird)
Passive
Shoulder abducted to 90, elbow

flexed to 90 and forearm internally rotated

Slide used with permission from Drs. Meg Pearson and Steve Bent

Supraspinatus: Empty can

Arm is abducted in the plane of the scapula and thumb pointed to the ground. Examiner pushes down on the arm, looking for pain (rotator cuff tendinitis) and or weakness (possible rotator cuff tear).

Subscapularis: Belly press Infraspinatus and teres minor: Resisted external rotation

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How to Do a Subacromial Shoulder Injection

Carlin Senter, MD Associate Professor Primary Care Sports Medicine University of California San Francisco

Watch: How to do a Subacromial Shoulder Injection Video

https://youtu.be/m3ukkCBTie8

Indication: Shoulder impingement. Neer’s test

Indication: Shoulder impingement. Hawkins test

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Benefits of subacromial injections in rotator cuff disease?

2003 Cochrane review: maybe small benefit for SA injection for RC

disease (impingement, tendinopathy, partial tear) over placebo at 4wks

Difficult to pool data
Variations in how patients diagnosed
Different types of injections
Different locations of injections (accuracy?)
Various study designs (lack RCTs)

Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003.

Randomized 100 impingement syndrome patients
Subacromial injxns (up to 3x, 1 month apart)
Physical therapy x 6 sessions
After 1 year both groups 50% better
10 injxn people crossed over to PT
9 PT people crossed over to injxn

Annals Int Med 8/2014.

Risks of corticosteroid use in rotator cuff disease?

Patients with ≥ 4 steroid injections had worse outcomes after

surgery for large-massive RTC tear (Watson M. J Bone Joint Surg Br. 1985)

1 dose steroid in SA space significantly reduces strength of rat

RTC (both injured and not injured) @ 1 week. No change compared to control at 3 and 5 weeks. (Mikolyzk DK et al. J Bone Joint Surg

Am. 2009)
Patients with 2 or more SA injections in the year prior to

rotator cuff repair were more likely to have revision surgery

(Desai VS et al. Arthroscopy 2018)

Risks of steroid injection in the subacromial space

Diabetics: increased blood sugar
Facial flushing: 10% with Kenalog
19-36 hours post-injection
Skin or fat atrophy
Post-injection steroid flare: 1-10%
Synovitis in response to injected crystals
Within hours - 48 hours post-injection
More common in soft tissue injections (20% of trigger points) than intra-articular injections
Infection: 1/3000-1/50,000
1-2 days after injection

Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2017. Accessed 12/1/18.

SLIDE 19

Aspiration/injection supplies

Betadine swab x 3
Ethyl chloride spray
Alcohol swabs x 6
4x4 gauze x 1
Bandaid x 1

Needles, syringes, meds

Needle to draw up meds
22g 1.5 inch needle to inject
10cc syringe
2-5 cc lidocaine
Steroid (I use 40mg, 1 cc, triamcinolone)

Approach

1. Posterior
2. Lateral

Lateral approach most accurate when using landmarks to guide injection, especially in women.

(Marder et al. JBJS 2012, Ganokroj et al. Orthopedics 2018.)

Photo courtesy of Anthony Luke, M.D.

Subacromial injection

Posterior approach Landmarks

Posterior and lateral borders of

acromion

Coracoid

Technique

Insert needle at Posterior “soft spot”
Aim parallel to angle of lateral

acromion to reach subacromial bursa

Direct needle towards ipsilateral

coracoid

Ganokroj P et al. Orthopedics. 11/2018

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Subacromial Injection

Lateral approach

Patient sitting up, hands placed in lap
Ask patient to relax shoulder and neck

muscles

Can apply traction to flexed elbow to open

subacromial space

Mark midpoint of lateral edge of acromion
Enter 1-1.5” below marked spot
Angle of entry parallel to acromion

(directed slightly cephalad and anterior)

UpToDate “Joint aspiration or injection in adults: Technique and indications. Updated 10/2017. Accessed 12/1/18.

Posterior or lateral approach

Ganokroj P et al. Orthopedics. 11/2018

SLIDE 21

UCSF CME: Essentials of Women’s Health July 2019 The Essential Physical Exam of the Shoulder for the Primary Care Clinician

Physical exam checklist

Maneuver Notes Inspection ‐ infraspinatus atrophy, skin findings Palpation  AC joint  Long head biceps tendon Active range of motion, bilateral  Abduction  Forward flexion  External rotation  Internal rotation Passive range of motion  Abduction to 90  External rotation at 90  Internal rotation at 90 Impingement:  Hawkins test  Neers test Rotator cuff strength:  Empty can  Belly press  Resisted external rotation