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 quadriceps muscles merge to form the The quadriceps quadriceps tendon… patellar tendon muscles extend the knee http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/Thigh+and +Leg+‐+Lecture+Notes Pes anserine bursa The hamstrings flex the knee www.hep2go.com http://meded.ucsd.edu/clinicalmed/joints.htm 2
7/27/2017 There are 4 Meniscus main ligaments in the knee Musculoskeletal work‐up Knee exam • H istory • I nspection • P alpation • R ange of motion • O ther T ests 3
7/27/2017 Diagnosis of knee osteoarthritis Common Causes of Knee Pain by Location of Symptoms • Anterior: • Medial - Medial joint-line: meniscus - Patellofemoral syndrome tear or OA - Quadriceps tendinitis - MCL sprain - Patellar tendinitis - Pes anserine bursitis • Lateral: • Posterior - Lateral jointline: meniscus tear - Hamstring tendinitis or OA - Gastrocnemius strain - IT band syndrome - OA, meniscus tears, - LCL sprain (rare) effusion, popliteal cyst…. - Fibular head: fracture (rare) Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039‐49. Palpation of joint line Inspection seated or supine http://www.rheumors.com/kneeexam/palpation.html http://doctorhoang.wordpress.com/20 http://meded.ucsd.edu/cl 10/09/06/valgus‐knee‐and‐bunion/ inicalmed/joints.htm 4
7/27/2017 Palpation of patella - supine Palpation of patellar facet Ballottement Knee range of motion Other Tests: Lachman to evaluate ACL Sensitivity 75‐100% Specificity 95‐100% • 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 Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008. Dr. Charles Goldberg, UCSD 5
7/27/2017 MCL and LCL PCL: Posterior Drawer MCL and LCL grading 4 tests for meniscus tear 1. Isolated joint line tenderness Grade Injury Translation Patient compared to response 2. McMurray unaffected 3. Thessaly side I Strain Minimal laxity, Pain 4. Squat firm endpoint II Partial tear Some laxity, Pain, may feel These tests not needed in patients with knee OA. firm endpoint loose Do these tests in patients < 50 with isolated joint III Complete tear Obvious laxity, Minimal pain, no endpoint may feel very line tenderness. loose 6
7/27/2017 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008. Meniscus: Squat Knee exam practice • Standing: inspection • Supine – Varus or valgus – Patellar facets • Sitting: palpation – Patellar grind – ROM – Joint line – Special tests – Femoral condyles • Lachman – Tibial plateau • Posterior drawer – Fibular head • Varus 0 and 30 • Valgus 0 and 30 • McMurray medial and lateral • Thessaly • Squat 7
7/27/2017 Underlying Anatomy ‐ Bones Shoulder anatomy Acromion Greater Tuberosity • Humerus Clavicle • Scapula o Glenoid o Acromion o Coracoid o Scapular body • Clavicle • Sternum Glenohumeral Joint Lesser Tuberosity The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa Spine of Acromion scapula is at the level of T3 Bottom of scapula is at level of T7 8
7/27/2017 Supraspinatus (Abduction ) The Rotator Cuff Muscles (SITS) The tendons of the rotator cuff muscles reinforce the capsule Greater of the glenohumeral Tubersosity Posterior joint. View Lesser Tuberosity Infraspinatus (External rotation)) Anterior View Teres Minor Subscapularis (External rotation) (Internal Rotation) The Biceps Muscle Shoulder exam • #1 Supination of the elbow (screwing, twisting) • #2 Flexion of the elbow Long head 3 attachments: • Radial tuberosity (distal) • Glenoid (long head) • Coracoid (short head) Short head 9
7/27/2017 Shoulder examination Neck examination Special Tests: Key Components of the • Inspection • Hawkins impingement sign Shoulder Exam: • Neers impingement sign ‐ Neck • • Palpate CS Painful arc (rotator cuff dz) • ‐ Shoulder Jobe’s, aka Empty‐can (supraspinatus) • • FF and extension Drop arm test (rotator cuff dz) ‐ Inspection • External rotation lag test (rotator cuff tear) ‐ Palpation • Internal rotation lag test (rotator cuff tear) • Spurlings ‐ Range of Motion: • Speeds (biceps) • abduction, flexion, ER, IR Yergason’s (biceps) • O’briens (SLAP tear) ‐ Strength • AC crossover (AC joint OA or sprain) ‐ Neurovascular Cervical Spine Shoulder examination Spurling’s Maneuver • Inspection • Neck extended – Patient in gown • Head rotated toward • Palpation affected shoulder • Axial load placed on • ROM the cervical spine • Strength • Reproduction of – Supra patient’s – Infra and teres shoulder/arm pain minor indicates possible – Subscapularis nerve root • Other tests http://meded.ucsd.edu/clinicalmed/joints compression 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM 10
7/27/2017 Shoulder examination Inspection • Inspection • Presence of infraspinatus atrophy increases • Palpation likelihood of rotator cuff disease • Positive LR 2.0 • ROM http://meded.ucsd.edu/clinic • Strength • Negative LR 0.61 almed/joints2.htm, permission granted by Dr. – Supraspinatus Charles Goldberg, UCSD SOM – Infraspinatus & Teres minor – Subscapularis • Other tests Litaker D et al, J Am Geriatr Soc, 2000. Range of motion Range of motion Internal rotation Abduction External rotation Flexion 11
7/27/2017 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 Shoulder: diagnosis driven exam • Neck: palpation, ROM and Spurling’s maneuver Active ROM • Inspection Normal Decreased • Palpation • AROM Weak = Rotator cuff tear – Abduction Limited by pain = Passive ROM – Flexion Other rotator cuff dz Normal Labral tear – External rotation (ER) Decreased Biceps tendinitis – Internal rotation (IR) 1 AC joint OA • PROM GH joint Xray OA Frozen Normal shoulder Abnormal 12
7/27/2017 Other tests Rotator cuff disease exam • Rotator cuff disease (RCD) • Pain provocation tests • Pain and strength tests – Bursitis or impingement • Often the pain radiates to lateral shoulder/proximal arm (“deltoid”) – Tendinitis/tendinopathy – Partial tear – Full thickness tear • Biceps tendinitis/tendinopathy • Labral tear • AC joint osteoarthritis Pain test: Impingement signs Pain test: Painful arc If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD. Hawkin’s Neer’s JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Photos from Dr. Christina Allen 13
7/27/2017 Exam practice: Pain & Strength test: pain provocation tests in RCD Supraspinatus = abduction • Hawkins impingement sign Supraspinatus • Neers impingement sign • Painful arc (rotator cuff dz) 2 71% sensitivity Empty can 41% specificity for (aka Jobe’s) rotator cuff disease. (+) LR 1.3 Photos from Dr. Christina Allen Physical exam maneuvers that increase Pain/strength test: Drop arm test likelihood of full thickness rotator cuff tear 1. External rotation Positive LR 3.3, lag test negative LR 0.82 2. Internal rotation for rotator cuff lag test disease. https://www.healthbase.com/hb/images/cm/p rocedures/orthopedics/rotator_cuff_tear.jpg JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 14
7/27/2017 Strength test: Pain & Strength test: External rotation lag test Subscapularis = internal rotation lag test Positive LR 7.2, Negative LR 0.57 Positive LR 5.6, for full thickness negative LR rotator cuff tear 0.04 for full thickness rotator cuff tear JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Exam practice: Biceps Tests: Speeds Rotator cuff strength and tear Tests for biceps pathology • Jobe’s, aka Empty‐can (rotator cuff disease) (tendinitis, tendinopathy, • Drop arm (rotator cuff disease) tear) • External rotation lag test (rotator cuff tear) Palms up, patient pushes • Internal rotation lag test aka Lift‐off test up against resistance (resisted elbow flexion) (rotator cuff tear) +Test is pain at proximal biceps tendon 3 Sens = 54%, Spec = 81% 15
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