Mastering the Musculoskeletal Exam WE HAVE NOTHING UCSF Essentials - - PDF document

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Mastering the Musculoskeletal Exam WE HAVE NOTHING UCSF Essentials - - PDF document

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7/27/2017 Mastering the Musculoskeletal Exam WE HAVE NOTHING UCSF Essentials of Primary Care TO DISCLOSE August 8, 2017 Carlin Senter, M.D. Henry Crevensten, M.D. Outline Knee exam Shoulder exam Knee Anatomy 1 7/27/2017 The

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Mastering the Musculoskeletal Exam

UCSF Essentials of Primary Care August 8, 2017 Carlin Senter, M.D. Henry Crevensten, M.D.

WE HAVE NOTHING TO DISCLOSE

Outline

  • Knee exam
  • Shoulder exam

Knee Anatomy

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The quadriceps muscles extend the knee

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

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

The hamstrings flex the knee

www.hep2go.com

Pes anserine bursa

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

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7/27/2017 3 There are 4 main ligaments in the knee

Meniscus Knee exam Musculoskeletal work‐up

  • History
  • Inspection
  • Palpation
  • Range of motion
  • Other Tests
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Common Causes of Knee Pain by Location of Symptoms

  • Anterior:
  • Patellofemoral syndrome
  • Quadriceps tendinitis
  • Patellar tendinitis
  • Lateral:
  • Lateral jointline: meniscus tear
  • r OA
  • IT band syndrome
  • LCL sprain (rare)
  • Fibular head: fracture (rare)
  • Medial
  • Medial joint-line: meniscus

tear or OA

  • MCL sprain
  • Pes anserine bursitis
  • Posterior
  • Hamstring tendinitis
  • Gastrocnemius strain
  • OA, meniscus tears,

effusion, popliteal cyst….

Diagnosis of knee osteoarthritis

Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039‐49.

Inspection

http://doctorhoang.wordpress.com/20 10/09/06/valgus‐knee‐and‐bunion/ http://meded.ucsd.edu/cl inicalmed/joints.htm

Palpation of joint line seated or supine

http://www.rheumors.com/kneeexam/palpation.html

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Palpation of patella - supine Ballottement Palpation of patellar facet Knee range of motion

  • 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 sports surgeon for arthroscopy

Permission for use provided by

  • Dr. Charles Goldberg, UCSD

Other Tests: Lachman to evaluate ACL

Sensitivity 75‐100% Specificity 95‐100%

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

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PCL: Posterior Drawer MCL and LCL MCL and LCL grading

Grade Injury Translation compared to unaffected side Patient response I Strain Minimal laxity, firm endpoint Pain II Partial tear Some laxity, firm endpoint Pain, may feel loose III Complete tear Obvious laxity, no endpoint Minimal pain, may feel very loose

4 tests for meniscus tear

  • 1. Isolated joint line tenderness
  • 2. McMurray
  • 3. Thessaly
  • 4. Squat

These tests not needed in patients with knee OA. Do these tests in patients < 50 with isolated joint line tenderness.

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Meniscus: McMurray

Sensitivity medial 65%, Specificity medial 93%

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

Meniscus: Thessaly Meniscus: Squat Knee exam practice

  • Standing: inspection

– Varus or valgus

  • Sitting: palpation

– Joint line – Femoral condyles – Tibial plateau – Fibular head

  • Supine

– Patellar facets – Patellar grind – ROM – Special tests

  • Lachman
  • Posterior drawer
  • Varus 0 and 30
  • Valgus 0 and 30
  • McMurray medial and

lateral

  • Thessaly
  • Squat
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Shoulder anatomy

Underlying Anatomy ‐ Bones

  • Humerus
  • Scapula
  • Glenoid
  • Acromion
  • Coracoid
  • Scapular body
  • Clavicle
  • Sternum

Glenohumeral Joint Clavicle Lesser Tuberosity Greater Tuberosity Acromion

The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa

Spine of scapula is at the level

  • f T3

Bottom

  • f

scapula is at level

  • f T7

Acromion

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The tendons of the rotator cuff muscles reinforce the capsule

  • f the glenohumeral

joint.

Subscapularis (Internal Rotation)

Anterior View

The Rotator Cuff Muscles (SITS)

Lesser Tuberosity

Infraspinatus (External rotation)) Teres Minor (External rotation) Supraspinatus (Abduction) Posterior View

Greater Tubersosity

The Biceps Muscle

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

3 attachments:

  • Radial tuberosity (distal)
  • Glenoid (long head)
  • Coracoid (short head)

Long head Short head

Shoulder exam

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Shoulder examination

Special Tests:

  • Hawkins impingement sign
  • Neers impingement sign
  • Painful arc (rotator cuff dz)
  • Jobe’s, aka Empty‐can (supraspinatus)
  • Drop arm test (rotator cuff dz)
  • External rotation lag test (rotator cuff tear)
  • Internal rotation lag test (rotator cuff tear)
  • Speeds (biceps)
  • Yergason’s (biceps)
  • O’briens (SLAP tear)
  • AC crossover (AC joint OA or sprain)

Key Components of the Shoulder Exam: ‐ Neck ‐ Shoulder ‐ Inspection ‐ Palpation ‐ Range of Motion: abduction, flexion, ER, IR ‐ Strength ‐ Neurovascular

Neck examination

  • Inspection
  • Palpate CS
  • FF and extension
  • Spurlings

Cervical Spine

Spurling’s Maneuver

  • Neck extended
  • Head rotated toward

affected shoulder

  • Axial load placed on

the cervical spine

  • Reproduction of

patient’s shoulder/arm pain indicates possible nerve root compression

Shoulder examination

  • Inspection

– Patient in gown

  • Palpation
  • ROM
  • Strength

– Supra – Infra and teres minor – Subscapularis

  • Other tests

http://meded.ucsd.edu/clinicalmed/joints 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

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Inspection

  • Presence of infraspinatus atrophy increases

likelihood of rotator cuff disease

  • Positive LR 2.0
  • Negative LR 0.61

Litaker D et al, J Am Geriatr Soc, 2000.

Shoulder examination

  • Inspection
  • Palpation
  • ROM
  • Strength

– Supraspinatus – Infraspinatus & Teres minor – Subscapularis

  • Other tests

http://meded.ucsd.edu/clinic almed/joints2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

Range of motion Abduction Flexion Range of motion

External rotation Internal rotation

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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

  • Neck: palpation, ROM and Spurling’s maneuver
  • Inspection
  • Palpation
  • AROM

– Abduction – Flexion – External rotation (ER) – Internal rotation (IR)

  • PROM

1

Shoulder: diagnosis driven exam

Active ROM Decreased Normal Passive ROM Normal Decreased Xray Frozen shoulder Normal GH joint OA Abnormal Weak = Rotator cuff tear Limited by pain = Other rotator cuff dz Labral tear Biceps tendinitis AC joint OA

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Other tests

  • Rotator cuff disease (RCD)

– Bursitis or impingement – Tendinitis/tendinopathy – Partial tear – Full thickness tear

  • Biceps tendinitis/tendinopathy
  • Labral tear
  • AC joint osteoarthritis

Rotator cuff disease exam

  • Pain provocation tests
  • Pain and strength tests
  • Often the pain radiates to lateral shoulder/proximal arm (“deltoid”)

Pain test: Impingement signs

Hawkin’s Neer’s

Photos from Dr. Christina Allen

Pain test: Painful arc

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD.

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Exam practice: pain provocation tests in RCD

  • Hawkins impingement sign
  • Neers impingement sign
  • Painful arc (rotator cuff dz)

2

Pain & Strength test: Supraspinatus = abduction

Empty can (aka Jobe’s)

Photos from Dr. Christina Allen

Supraspinatus 71% sensitivity 41% specificity for rotator cuff

  • disease. (+) LR 1.3

Pain/strength test: Drop arm test

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Positive LR 3.3, negative LR 0.82 for rotator cuff disease.

Physical exam maneuvers that increase likelihood of full thickness rotator cuff tear

  • 1. External rotation

lag test

  • 2. Internal rotation

lag test

https://www.healthbase.com/hb/images/cm/p rocedures/orthopedics/rotator_cuff_tear.jpg

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Strength test: External rotation lag test

Positive LR 7.2, Negative LR 0.57 for full thickness rotator cuff tear

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Pain & Strength test: Subscapularis = internal rotation lag test

  • JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear

Exam practice: Rotator cuff strength and tear

  • Jobe’s, aka Empty‐can (rotator cuff disease)
  • Drop arm (rotator cuff disease)
  • External rotation lag test (rotator cuff tear)
  • Internal rotation lag test aka Lift‐off test

(rotator cuff tear)

3

Biceps Tests: Speeds

Tests for biceps pathology (tendinitis, tendinopathy, tear) Palms up, patient pushes up against resistance (resisted elbow flexion) +Test is pain at proximal biceps tendon Sens = 54%, Spec = 81%

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Biceps Tests: Yergasons

Tests for biceps pathology (tendinitis, tendinopathy, tear) Patient supinates (twists

  • ut) against resistance

+Test is pain at proximal biceps tendon Also tests for biceps strength Sens = 41%, Spec = 79%

O’Brien’s Test

To r/o Labral Tear

  • 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%

Testing the AC Joint: AC Crossover

  • Tests for AC joint
  • steoarthritis or

sprain

  • Can be done

passively by patient or physician

  • +Test is pain at

AC joint

Exam practice: biceps tendinitis, labral tear, AC OA

  • Speeds (biceps)
  • Yergason’s (biceps)
  • O’briens (SLAP tear)
  • AC crossover (AC joint OA or sprain)

4

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Shoulder examination

Special Tests:

  • Hawkins impingement sign
  • Neers impingement sign
  • Painful arc (rotator cuff dz)
  • Jobe’s, aka Empty‐can (supraspinatus)
  • Drop arm test (rotator cuff dz)
  • External rotation lag test (rotator cuff tear)
  • Internal rotation lag test (rotator cuff tear)
  • Speeds (biceps)
  • Yergason’s (biceps)
  • O’briens (SLAP tear)
  • AC crossover (AC joint OA or sprain)

Key Components of the Shoulder Exam: ‐ Neck ‐ Shoulder ‐ Inspection ‐ Palpation ‐ Range of Motion: abduction, flexion, ER, IR ‐ Strength ‐ Neurovascular

Thank you

Questions? Carlin.Senter@ucsf.edu