u 8/12/2016 Disclosures ESSENTIALS OF PRIMARY CARE: A Core Curriculum for Ambulatory Practice August 7-12, 2016 I have nothing to disclose 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 Objective Important Points n With a good history…you should arrive at the correct n Perform an effective diagnosis 90% of the time problem-focused history Or at least a confident top 3 differential! and physical examination � for evaluation and treatment of n With a good history, and comfortable knowledge of musculoskeletal complaints basic anatomy…it will make your exam focused, involving the knee, quick and efficient shoulder, and ankle u And give you more time to chart… n 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! u 1
u 8/12/2016 Knee - History Exam Room Tips Age 1. Date of injury/sx onset 2. n Stock gowns/sheets and paper shorts in the room Injury Mechanism: 3. n Be able to get to both sides of the exam table Acute: pop, ability to continue activity a. n Always have 2 pillows Chronic/Overuse: precipitating activity b. n Have a step stool handy Swelling: location and timing 4. Symptoms: Mechanical 5. a. locking, clicking, instability, grinding, weakness Symptoms: Pain 6. Location - Point to where it is a. Radiation - come from or go anywhere else b. Type - burning, sharp, dull, achy, constant, at night, c. w/ activity or position Modifying Factors 7. Better/worse, previous injury or surgery a. Lateral Knee Medial Knee u 2
u 8/12/2016 Anterior Knee Pain Knee – Posterior Knee – A systematic exam Knee – A systematic exam n Observation: effusion, swelling, abrasions, scars n Patella u patellar apprehension test n Sitting: check effusion, knee extension u Palpation of medial/lateral patellar facets/plica/MPFL n Ligament testing: u patellar tendon and tibial tuberosity u Lachman’s (ACL) u patellar compression test u Varus/valgus stress testing (MCL/LCL) n Special Tests: u Post drawer (PCL) u Nobles test n ROM u Thomas test u Popliteal angle (hamstring)/SLR u Sidelying abduction testing/Ober u Hip and knee u Apleys test/Thessaly test u Fig 4 – palpate LCL u Single leg balance/squat n Meniscus n Stance/Foot type u Palpate joint lines, med/lat condyles, check effusion u McMurray's test n Gait u Bounce test n NVI distally u 3
u 8/12/2016 Ankle - History Ankle Anatomy- Anterior Age 1. Date of injury/sx onset 2. Injury Mechanism: 3. Acute: pop, ability to continue activity a. Chronic/Overuse: precipitating activity b. Swelling: location and timing 4. Symptoms: Mechanical 5. a. locking, clicking, instability, grinding, weakness Symptoms: Pain 6. Location - Point to where it is a. Radiation - come from or go anywhere else b. Type - burning, sharp, dull, achy, constant, at night, c. w/ activity or position Modifying Factors 7. Better/worse, previous injury or surgery a. Ankle Anatomy-Lateral Ankle Anatomy-Medial u 4
u 8/12/2016 Ankle Anatomy-Posterior Ankle – A systematic exam n Observation: effusion, swelling, ecchymosis Squeeze test (fibular head, 5 th MT pain) n n Stabiilty/Ligament testing: u Anterior drawer u Talar tilt: lateral and medial u Talar shift n ROM F Normal: >15 ° dorsiflexion to >45 ° Plantarflexion u Ankle: F Slightly decreased: 5-15 ° DF to 20-45 ° PF F Significantly Decreased: < 5 ° DF to <20 ° PF F 2/3 to 1/3 inversion to eversion (20 ° to 10 ° ) u Subtalar: Ankle – A systematic exam Ankle – A systematic exam n Special Tests: n Strength Testing u Syndesmosis stress test: forced DF/external rotation u DF, PF, Eversion, Inversion u Thompson test for Achilles u (EHL strength) u Calcaneal squeeze test n Focal Tenderness u Slump test to rule out radiculopathy u Medial malleolus, and at level of physis u Bilateral heel raise u Medial deltoid ligaments u Single leg balance/squat u Lateral malleolus, and at level of physis n Stance u Lateral Ligaments: u Foot type F ATFL, CFL, PTFL n Gait u Syndesmosis: n NVI distally F AITFL, PITFL u Talar dome u Tarsal Tunnel, Post tibialis tendon, Peroneal tendons u 5
u 8/12/2016 Shoulder - History “Arm not fine? First clear the spine!” Age 1. Date of injury/sx onset 2. Injury Mechanism: 3. Acute: pop, ability to continue activity a. Chronic/Overuse: precipitating activity b. Swelling: location and timing 4. Symptoms: Mechanical 5. a. locking, clicking, instability, grinding, weakness Symptoms: Pain 6. Location - Point to where it is a. Radiation - come from or go anywhere else b. Type - burning, sharp, dull, achy, constant, at night, c. w/ activity or position Modifying Factors 7. Better/worse, previous injury or surgery a. Shoulder – Ant and Post Shoulder – Superior u 6
u 8/12/2016 Shoulder – A systematic exam Shoulder – A systematic exam n C-spine FROM no pain n Focal Tenderness u Spurling neg u SC joint, AC joint, clavicle, acromion, subacromial n Observation: Ecchymosis, deformity, atrophy, bursa, coracoid, biceps tendon, supraspinous fossa scars, asymmetry n Special Tests n ROM comparison (active first, then passive) u Instability u FF, ABD F Sulcus sign, Ant-post glide, Posterior shift F Scapular motion u ER, IR @ 0 ° and 90 ° F Apprehension/Relocation u Horizontal ADD u Impingement F Hawkins, Neer's u EXT, IR/ADD (level of vertebrae) u Rotator Cuff and Labrum F Drop Arm, Dropping sign, Hornblower’s sign n Strength testing F Speeds, Yergasons, O'Briens, Biceps Load test u Lift-off test, Belly-press test n NVI distally u FF, ABD, Suprapinatus u ER, IR Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand. - Chinese proverb u 7
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