Mastering the Musculoskeletal Exam WE HAVE NOTHING TO … · 2017-07-31 · 7/27/2017 1 Mastering...

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Mastering the Musculoskeletal Exam

UCSF Essentials of Primary CareAugust 8, 2017

Carlin Senter, M.D.Henry Crevensten, M.D.

WE HAVE NOTHINGTO DISCLOSE

Outline

• Knee exam

• Shoulder examKnee 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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There are 4 main ligaments in the knee

Meniscus

Knee examMusculoskeletal 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 or 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/2010/09/06/valgus‐knee‐and‐bunion/

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

Palpation of joint lineseated 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 ACLSensitivity 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 anatomyUnderlying Anatomy ‐ Bones

• Humerus• Scapula

o Glenoido Acromiono Coracoido 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 ofscapula isat the levelof T3

Bottom of scapula is at level of T7

Acromion

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The tendons of the rotator cuffmuscles reinforce the capsule of the glenohumeraljoint.

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 SpineSpurling’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


• Inspection– Patient in gown

• Palpation

• ROM

• Strength– Supra

– Infra and teresminor

– Subscapularis

• Other tests http://meded.ucsd.edu/clinicalmed/joints2.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.


• Inspection

• Palpation• ROM

• Strength– Supraspinatus

– Infraspinatus & Teres minor

– Subscapularis

• Other tests

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

DecreasedNormal

Passive ROM

Normal

Decreased

Xray

Frozen shoulder Normal

GH joint OA

Abnormal

Weak = Rotator cuff tear

Limited by pain = Other rotator cuff dz

Labral tearBiceps 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’sPhotos 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)

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Pain & Strength test: Supraspinatus = abduction

Empty can(aka Jobe’s)

Photos from Dr. Christina Allen

Supraspinatus

71% sensitivity41% specificity for rotator cuff disease. (+) LR 1.3

Pain/strength test: Drop arm test


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/procedures/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


Pain & Strength test:Subscapularis = internal rotation lag test


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)

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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 out) against resistance

+Test is pain at proximal biceps tendonAlso tests for biceps strength

Sens = 41%, Spec = 79%

O’Brien’s TestTo 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 osteoarthritis 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)

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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?

[email protected]

Mastering the Musculoskeletal Exam WE HAVE NOTHING TO … · 2017-07-31 · 7/27/2017 1 Mastering...

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