Examining the Physical Exam problems How to Make Yours Better - PDF document

Overview Quick approach to MSK Examining the Physical Exam problems How to Make Yours Better • History – what does it mean? • Considering the differential diagnosis A n t h o n y L u k e • Physical exam – MD, MPH, CAQ (Sport Med) confirm the diagnosis University of California, San Francisco Primary Care Medicine: Update 2017 Is the patient? • Age • Occupation/Activity • Recreational, competitive, or elite • Handedness • Past medical history • Family history Manage patient expectations “The patient will tell you what the problem is” 1

Age factor is the Chief Complaint? Children The BIG THREE • Tendons and ligaments 1. Pain relatively stronger than 2. Instability epiphyseal plate 3. Dysfunction • Insertional overuse injuries • Other complaints: (OSD, SLJ, Sever’s) swelling, numbness Elderly and tingling, • Decreased flexibility decreased performance • Apoptosis – “programmed” cell death; repair affected Swelling Bone Pain • Intra-articular vs. • Constant extra-articular • Sharp • Greater load = • Consider onset of swelling greater pain (i.e. 1) Immediate - minutes weightbearing) 2) In 24 hours • May have pressure 3) Insidious - days features 2

Tendon Pain Onset of injury? • May be present at the start of an activity then “warm-up” • Acute • Chronic • Sore when the muscle is used • Acute on Chronic • May occur in “compensation” for other structural problems near by • Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD L i g a m e n t Mechanism of Injury? Anatomy and Biomechanics Ultimate Ligament Tension Failure • ACL: 2200 N (Anterior) • PCL: 2500 N (Posterior) • MCL: 4000N (Valgus) • LCL: 750N (Varus) • Posteromedial Corner • Posterolateral Corner 3

Biomechanical Studies is the injury located? Forces on the ACL/Graft • Think about structures • Level Walking = 169 N in injured area • Ascending Stairs = 67 N • Is the pain referred? • Descending Stairs = 445 N • The one-finger test Morrison, Biomech, 1970 • Know your anatomy Morrison, Bio Eng,1968,1969 • Normal Walking = 400 N • Sharp Cutting = 1700 N Butler, Clin Orthop, 1985 • Sports = 2000+ N Red Flag Symptoms Intrinsic Risk Factors Extrinsic Risk Factors • Severe disability • Growth • Training • Numbness and tingling • Anatomy • Technique • Night pain • Muscle/Tendon • Footwear imbalance • Constitutional symptoms (fever, wt loss) • Surface • Illness • Occupation • Swelling with no injury • Nutrition • Systemic illness • Conditioning • TO PREVENT • Multiple joint injury • Psychology INJURIES!! 4

First Test - Physical Exam Physical exam Physical Exam SPECIAL TESTS • Confirms or excludes the suspected LOOK – Observation Provocative tests diagnosis • Swelling, Erythema, • Reproduce patient’s pain Atrophy, Deformity, • Tests are often non-specific Surgical Scars (SEADS) Stress tests • Groups of tests can improve sensitivity • Stress structures for FEEL – Palpate important instability (i.e. ligaments) and specificity structures Functional tests MOVE – Assess Range of • Assess functional Motion movements (i.e. weight bearing activity) Always check Neurovascular Status Other physical exam Case - Knee Swelling 22 year old Skier comes has twisting • Alignment injury in her knee • Motor strength skiing. Develops immediate swelling • Flexibility of agonists after injury and has and antagonists to be brought down • Neurologic by ski patrol • Check the joint above and the joint below • THINK KINETIC CHAIN 5

Look (Standing) Look (Supine) • Alignment “SEADS” • Ankles together • Swelling • Ankles apart • Erythema • On toes • Atrophy • Walk • Deformity • Red flag – can’t do it • Surgical scars • Hop test Feel Feel Patella • Bulge sign • Tender over facets • “Milk medially, push of patella laterally” • Apprehension sign suggests possible • (Patellar tap) instability 6

Feel - Patellar mobility Feel Joint Line Special Tests ACL Special Tests ACL • Lachman's test – test at • Lachman's test – test at 20° 20° Sens 81.8%, Spec 96.8% Sens 81.8%, Spec 96.8% • Anterior drawer – test at • Anterior drawer – test at 90° 90° Sens 22 - 41%, Spec 97%* Sens 22 - 41%, Spec 97%* • Pivot shift • Pivot shift Sens 35 - 98.4%*, Spec 98%* Sens 35 - 98.4%*, Spec 98%* Malanga GA, Nadler SF. Malanga GA, Nadler SF. Musculoskeletal Physical Musculoskeletal Physical Examination, Mosby, 2006 Examination, Mosby, 2006 * - denotes under anesthesia * - denotes under anesthesia Drop Lachman test 7

Medial Collateral Ligament (MCL) Medial Collateral Ligament (MCL) Injury Injury Physical Exam Physical Exam • Tender medially over • Tender medially over MCL (often proximally) MCL (often • May lack ROM proximally) “pseudolocking” • May lack ROM • Valgus stress test – test “pseudolocking” at 20° • Valgus stress test Sens = 86 - 96 % Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 Posterior Cruciate Ligament (PCL) Posterior Cruciate Ligament (PCL) Injury Injury Physical Exam Mechanism Symptoms • Sag sign • Fall directly on knee • Pain with activities with foot plantarflexed Sens 79%, Spec 100% • “Disability” > • “Dashboard injury” “Instability” • Posterior drawer test Sens 90%, Spec 99% Rubenstein et al., Am J Sports Med, 1994; 22: 550-557 X-ray- often non-diagnostic MRI is test of choice 8

Special Tests: Meniscus Meniscus Tear Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186. Test Sensitivity Specificity Mechanism Symptoms • Occurs after twisting • Catching Joint line tender 85.5% 29.4% injury or deep squat • Medial or lateral knee Hyperflexion 50% 68.2% • Patient may not recall pain specific injury Extension block 84.7% 43.75% • Usually posterior aspects of joint line McMurray Classic 28.75% 95.3% (Med Thud) • Swelling McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5% 80% Modified McMurray Testing Thessaly Test • Flex hip to 90 • Hold patient’s hands for support degrees • Patient bends knee to 5 ° • Flex knee while he/she twists on knee • Internally or externally • Twisting movement will rotate lower leg with reproduce pain from rotation of knee meniscal injury • Repeat with 20 ° knee • Fully flex the knee flexion with rotations Medial side: Sens 89%, Spec 97% Lateral side: Sens. 92%; Spec 96% Karachalios et al. J Bone Joint Surg Am, 2005; 87: 955-962 Courtesy of Keegan Duchicella MD Courtesy of Keegan Duchicella MD 9

Ankle Injury Physical Exam 40 y.o. Male Tennis LOOK Symptoms player suffers • Swelling/bruising • Localized pain usually inversion injury to the laterally over the lateral aspect ankle FEEL Anterior of the ankle talofibular • Point of maximal ligament • Difficulty weight tenderness usually bearing, limping ATF Calcaneo • May feel unstable in fibular MOVE ligament the ankle • Limited motion due to swelling Special Tests Anterior Drawer Special Tests Anterior Drawer Test Test • Normal ~ 3 mm • Normal ~ 3 mm • Foot in neutral • Foot in neutral position position • Fix tibia • Fix tibia • Draw calcaneus • Draw calcaneus forward forward • Tests ATF ligament • Tests ATF ligament Sens = 80% Sens = 80% Spec = 74% Spec = 74% PPV = 91% PPV = 91% NPV = 52% NPV = 52% van Dijk et al. J Bone Joint van Dijk et al. J Bone Joint Surg-Br, 1996; 78B: 958-962 Surg-Br, 1996; 78B: 958-962 10

Subtalar Tilt Test Subtalar Tilt test • Foot in neutral position • Fix tibia • Invert or tilt calcaneus • Tests Calcaneofibular ligament No Sens / Spec Data Grading Ankle Sprains Ottawa Ankle Rules Grade Drawer/Tilt Pathology Functional • Inability to weight bear Recovery Test results immediately and in the emergency/ in weeks office (4 steps) 1 Drawer and Mild stretch 2 – 4 tilt negative, with no • Bone tenderness at the posterior but tender instability edge of the medial or lateral Sens = 97% malleolus (Obtain Ankle Series) 2 Drawer lax, ATFL torn, CFL 4 – 6 Spec = 31-63% • Bone tenderness over the tilt with good and PTFL PPV = 20% navicular or base of the fifth end point intact metatarsal (Obtain Foot Series) NPV = 99% 3 Drawer and ATFL and CFL 6 – 12 tilt lax injured/torn Am J Emerg Med 1998; 16: 564-67 11

“High Ankle” Sprains External Rotation Stress Test Mechanism • Fix tibia • Dorsiflexion, eversion • Foot in neutral injury • Dorsiflex and • Disruption of the externally Syndesmotic ligaments rotate ankle • Most commonly the anterior tibiofibular ligament No Sens/ Spec Data • R/O Proximal fibular Kappa = 0.75 fracture Alonso et al. J Orthop Sports Phys Ther, 1998; 27: 276-284 External Rotation Stress Test Squeeze test • Fix tibia • Hold leg at mid calf level • Foot in neutral • Squeeze tibia and • Dorsiflex and fibula together externally rotate ankle • Pain located over anterior tibiofibular ligament area No Sens/ Spec Data Kappa = 0.75 No Sens/ Spec Data Kappa = 0.50 Alonso et al. J Orthop Sports Phys Alonso et al. J Orthop Sports Phys Ther, 1998; 27: 276-284 Ther, 1998; 27: 276-284 12