Copyright 2002 CareGroup

Occupational Health Network

Provocative Testing & Diagnostics of Upper & Lower

Extremity Conditions

Tom Winters, MD, FACOEM, FACPM

Chief Medical Officer

CareGroup Occupational Health Network

Walter Panis, MD

Medical Director

CareGroup Occupational Health Network

June 6, 2002

The Knee

• Approx. 10.8 million knee injuries per year in general population

• Why so many injuries– Largest joint in body

– Dynamic nature of joint increases vulnerability

– Very little bony stability- relies on normal ligaments, cartilage and tendons

Ref: AAOS Research Dept., Pt. Visits for selected conditions, 1998

Anatomy of the Knee

• Bones:– Femur– Tibia– Patella

• Cartilage (shock absorbers)– Lateral Meniscus– Medial Meniscus– Articular cartilage is

nerveless

Anatomy of the Knee

• Ligaments– 4 major ligaments

(attach bone to bone)• Anterior Cruciate

• Posterior Cruciate

• Medial Collateral

• Lateral Collateral

Anatomy of the Knee

• Patellar and Extensor tendons (attach Quadriceps to bone)– Major tendons

• Synovium– Inner joint lining

• Synovial fluid– Joint lubrication

Types of Knee Injuries

• ACL tear• Bursitis (“Housemaids

knee”)• Collateral ligament

tear• Posterior ligament

tear• Meniscal tear

• Fracture of tibia• Fracture of patella• Sprain/strain• Patellar/quadriceps

tendinitis• Patellofemoral pain• Extensor mechanism

rupture

Types of Knee Injuries

• Ligament Injuries– ACL: changing direction

quickly, twisting, pivoting, deceleration activities

– PCL: blow to front of knee (“dashboard injury”), hyperextension / hyperflexion

– MCL: contact with outside of knee, valgus force (common)

– LCL: knee forced laterally, varus force (less common)

Types of Knee Injuries (cont.)

• Meniscal Tears– Medial/Lateral

Meniscal Tear:• Twisting,cutting,

pivoting, rapid deceleration types of motions

• Movement around a fixed lower leg (stationary) or planted foot

Examination of the Knee• Inspection (always examine

uninjured knee 1st!)– Note onset- acute/gradual– Type/quality of pain– Posture– Bony deformities– Muscle wasting

• Quad wasting esp. in VM O seen with knee injury

– Soft tissue swelling• Effusion of suprapatellar pouch,

pre and infrapatellar bursae, palpable joint line swelling

– Masses/lumps– Old scars– Pulses

Examination of the Knee (cont.)

• Palpation– Check bilaterally for temperature

differences, inflammation

– Palpate medial and lateral collateral compartments

– Bursae

– Medial/lateral meniscus

– Medial/lateral ligament• Medial more common

• “Bucket-handle” tear

– Popliteal fossa

Examination of the Knee (cont.)

• Palpation (cont.)– Bony landmarks

• Medial and lateral joint lines

• Patello-femoral joint

• Tibial tuberosity

• Femoral condyles

– Reflexes

– Always check joint above and below (hip and ankle); hip pain may be referred to knee!

Examination of the Knee (cont.)

• Range of motion– Flexion = 130+

degrees

– Extension = 0 - (-10) degrees

Special Knee Tests

• Tests for ACL laxity– Anterior drawer sign

– Lachman’s test

– Pivot shift

Anterior Draw Test

Lachman’s TestRef: Snider, R. The Essentials of Musculoskeletal Care. AAOS: 1997

Special Knee Tests (cont.)

• PCL stress tests– Posterior sag sign

– Reverse Lachman’s

– Posterior draw sign

– Reverse pivot test

http://www.wokc2.com/topic3.htm

Posterior sag sign

Special Knee Tests (cont.)

• McMurray’s/ Apley’s grind test (meniscus)

• Apprehension test (patella)

• Crepitus sub-patella

• Pathological “locking/giving out”– Due to intra-articular fragment

of bone or cartilage wedging between femoral & tibial condyles

– Joint unable to fully extend (fixed flexion deformity)

McMurray’s Test

Ref: Hoppenfeld,S. Physical Examination of the Spine & Extremities. Prentice-Hall: 1976.

Grading Ligament Injuries• Grade I (sprain):

– Micro-tearing or stretching– Joint is stable

• Grade II (sprain):– Partial disruption of ligament– Painful to stress joint– Joint laxity with endpoint– Mild effusion

• Grade III (tear):– Complete tear– Joint laxity without endpoint effusion

Diagnostic Procedures

• X-ray– Indications

• MRI– Best to view:

• Meniscus, ligaments, soft tissue

– Indications

• CAT Scan– Best to view:

• Bone

– Indications

Diagnostic Procedures

• Arthrogram (infrequently performed)

• Arthroscopy (preferred method)

Treatment of Knee Injuries

• Rest• Ice• Compression• Elevation• Anti-inflammatories

– NSAIDs

– COX-2

Types of Knee Braces• Types of bracing:

– Prophylactic– Functional– Rehabilitative/knee

immobilizer– Patellorfemoral

• Often work better in lab than in real life use

• Functional and Rehabilitative seem to be of most use

• Stretching, strengthening,and technique improvement more important in long run

Anatomy of the Foot and Ankle• Bones

– “True ankle joint”• Tibia• Fibula• Talus

Second part of ankle• Subtalar joint• Calcaneus (heal)

– Foot• Tarsals• Metatarsals• Phalanges

A.

                              

A.

                               

Ref: http://www.soarmedical.com/medical-library/foot&ankle/

Anatomy of the Foot and Ankle (cont.)

• Cartilage & ligaments– Articular cartilage (1)

– Anterior tibiofibular (2)• Connects tibia to fibula

• Most commonly injured

– Collateral lateral ligaments (3)• Attaches fibula to calcaneus-

lateral stability

– Deltoid ligaments (4)• Connect tibia to talus and

calcaneus- medial stability

                                                 

Ref: http://www.scoi.com/anklanat.htm

Anatomy of the Foot and Ankle (cont.)

• Tendons– Achilles tendon

– Anterior tibial tendon

– Posterior tibial tendon

Examination of the Ankle and Foot

• Inspection– Ecchymosis, bony abnormalities, soft tissue swelling, effusion– Note type of footwear- note wear pattern on soles– Gait

• Palpation– Tenderness- certain areas of foot normally tender i.e.sinus

tarsi, distal aspect of ball between metatarsals– Neurovascular status- Pulses, sensation– Crepitation– Tinel’s sign (+ peroneal nerve injury)

• Range of motion

Special Tests of the Ankle and Foot

• Eversion stress (Medial stress test)• Drawer test• Anterior drawer test (tests stability-ATF ligament)• Lateral stress• External rotation test (Kleiger test)• Squeeze test (testing for fx of

tibia or fibula)• Heel tap test

Types of Ankle and Foot Injuries

• Plantar fasciitis• Tarsal tunnel

syndrome (ladders)• Insertional Achilles

tendinitis• Stress fracture of

calcaneus

• March fracture (stress fx)

• Sesamoiditis• Fracture of the

sesamoid

Sprain versus Strain

• Sprain: twisting of joint that stretches or tears ligaments, no dislocation of bones, may damage nearby blood vessels, muscles, tendons, swelling and hemorrhage

• Strain: less serious injury, overstretched tendon or partially torn muscle

Types of Ankle Injuries:Sprains

• 1st degree: no (mild) edema, point tenderness, ligament stretching, no rupture (maybe crutches/cane)

• 2nd degree: partial ligament rupture, edema, point tenderness, difficulty/inability to weight bear on ankle (crutches,splint)

• 3rd degree: complete disruption one or more ligaments/other structures, edema, ecchymosis, general tenderness, inability to bear weight (crutches,splint, cast, surgery)

Ankle Sprains• Forced inversion strain

– Stretch, tear or rupture of lateral collateral ligament complex (possibly anterior talo-fibular lig.)

• Forced eversion strain– Stretch, tear or rupture of

medial collateral ligament

• Lateral ankle compartment more commonly injured than medial

Foot and Ankle Fractures

• Types– Jones (fx of proximal metaphysis of 5th

metatarsal)

• Diagnosis– Routine use of x-rays to rule out

sprain vs. fx “to do or not to do”- clinical indications

– Ottawa rules for foot and ankle radiographs (see web site) http://www.aafp.

org/afp/980201ap/wexler.html

• Treatment– ORIF– Casting

Foot and Ankle Fractures

Traumatic Injury

• Direct trauma = external force strikes the foot

• Indirect trauma = force transmitted to stationary foot so that weight of body becomes a deforming force by torque, rotation or, compression

Ref: http://www.aafp.org/afp/980700ap/burrough.html

• Why are ankle injuries so painful?– Rich nerve supply

(pain and proprioception is enhanced)

– All ligaments have poor blood supply: slow to heal, heals with scar tissue, retains stretched condition

Pain

Non-Surgical Treatment of Ankle Injuries

• Rest

• Ice

• Compression

• Elevation

Types of Ankle Support

• Non-rigid (1st degree sprains):– Elastic wrap/neoprene

• Not OSHA recordable• Purpose: compression, non-

supportive

• Rigid: (1st, 2nd, 3rd degree sprains)– Lace-up, Aircast

• Purpose: support, proprioception

– Bracing• AFO (ankle foot orthosis)• Walking boot• Cast shoe• Cast

Physical Therapy for Knee and Ankle Injuries

• Does every lower extremity injury require physical therapy?– Benefits

– How soon after injury should it be ordered?

• Home exercises versus clinic therapy program– Nature of injury

– Patient compliance issues

Goals of Rehabilitation

• Restoration of comfort– Decrease edema

• R.I.C.E.

– Address pain• NSAIDs• COX-2 agents

• Refer complications early• Maintain Mobility

– Active ROM & strengthening

• Restore proprioception– Wobble board, mini-

trampoline

• Work-hardening program or job specific exercise programs

• Prevent future re-injury– Education

• Understand injury, treatment, rehab and prevention strategies

Upper Extremity Evaluation

• History• Exam• Diagnostic studies• Key is putting all

three together to make a “total” picture

Low Back Pain

• Most commonly seen musculoskeletal injury

• In normal population 80% of us will have an LBP episode in their lifetime

• 3-4% per yr. Will be temporarily disabled

• 1% of working population will be permanently disabled

Ref: www.emedicine.com/neuro/topic516.htm

Myths of Low Back Pain

• True or false:– All people with LPB need an x-ray– Rest is good for pain– MRI or CT must be done to provide definitive

diagnosis– Vast majority of patients improve in 2-6 weeks

with or without treatment (approx. 90%)

Anatomy of the Lumbar Spine

• No lateral support in lumbar spine (> mobility in sagittal and coronal planes)

• Bony vertebrae– Transverse and spinous

processes

• Intervertebral disc– Outer annulus fibrosis

– Inner nucleus pulposus

Anatomy of the Lumbar Spine

• Anatomical relationship between L4, L5 and S1

Anatomy of the Lumbar Spine

• Specific nerve roots have specific functions and will elicit specific symptoms

Diagnosing Low Back Pain: Sprain/Strain Injury

• Vast majority of LBP is a sprain/strain injury– Ligamentous– Tendonitis

• LBP most often over R lumbar sacral area– Tends to be localized– Referred pain not

typically seen– Described as “aching”

Diagnosing Low Back Pain: Nerve Root Compression

• Back pain due to nerve root compression/radiculopathy less common– “Sciatica” is not a good term

• Sciatic nerve= combination of tibial and peroneal nerve- forms well outside spinal canal where most back problems occur

Diagnosing Low Back Pain: Nerve Root Compression

• Impingement compression pathology of spinal nerve root– Initial complaint may be “electric

shock down leg”• Mechanism= ICP due to

intrathoracic pressure venous outflow from brain ICP pressure on nerve from disc causing burning/shooting pain

– Parethesias• Numbness/tingling

– Bowel/bladder involvement• Cauda Equina Syndrome• Medical/surgical emergency

Diagnostic Studies for Low Back Pain

• X-rays– ? value

• MRI and CT scans– Asymptomatic disc

herniations are commonly found on What is diagnostic value of this?

– When should MRI or CT be done?

Two Common Presentations of Low Back Pain

• History:– 38 year old male experienced the following

after lifting a 100 pound box from the floor to a shelf at work

– 1) Localized back pain» OR

– 2) Very specific burning pain radiating to leg

Complaint #1

• Physical exam findings– Non-specific

– Reflexes normal

– ROM, gait, posture

– Palpation of spine

– Response to light touch

– Provocative testing done• Straight leg raise

• Heel to toe walk, squat and rise

• Palpation of sciatic notch

Complaint #1

• Diagnostic testing – Not usually indicated

unless red flags are present i.e. fever, wght. loss, hx of cancer, use of steroids etc.

• Likely diagnosis– Low back strain/sprain

Complaint #1

• Treatment– NSAIDs

– Physical therapy

– May need modified duty/work restrictions

– Importance of developing trusting relationship with patient to optimize outcome

• Lou Millender, MD– “Love ‘em back to

health!”

Complaint #2

• Physical exam– Specific– Motor weakness in

specific distribution– Abnormal reflexes– Sensory loss– Provocative testing

• ? Cauda Equina syndrome if unable to heel toe walk or squat

• + straight leg raise

Complaint #2

• Diagnostic testing– X-rays not useful

– MRI after 6 weeks of conservative treatment unless neuro symptoms

– Electrophysiology studies• What are they

• When are they done

• What will they show

• Likely diagnosis– Radiculopathy

Complaint #2

• Treatment– Most improve on own

– Pain control

– Physical therapy

– Prednisone/epidural steroids

– May need to be out of work for 1-2 days during acute symptoms

– Surgical intervention

– May require work restrictions/modified duty

Provocative Testing of the Shoulder

• Apley scratch test– Maneuver = touch

superior/inferior aspects of opposite scapula

– Positive result (< ROM) = rotator cuff problem

• Neer’s test– Maneuver = place arm in

forced flexion with arm fully pronated

– Positive result (pain) = sub-acromial impingement

Neer’s

Provocative Testing of the Shoulder

• Crossed arm test– Maneuver = raise arm

to 90 degrees then actively adduct arm- forces the acromion into the distal end of the clavicle

– Positive result (pain) = disorder of acromioclavicular joint

CROSSED ARM

Provocative Testing of the Shoulder

• Hawkin’s test– Maneuver = elevate arm forward

to 90 degrees while forcibly internally rotating shoulder

– Positive result (pain) = subacromial impingement or rotator cuff tendonitis

• Drop arm test– Maneuver = Passively abduct

shoulder, observe pt. lowering arm to waist

– Positive result (arm will drop to side) = rotator cuff tear

HAWKIN’S

Provocative Testing of the Elbow and Hand

• Phalen’s test– Maneuver = press back

of hands together with wrists fully flexed, hold 60 seconds

– Positive result (numbness/tingling) = carpal tunnel syndrome, median nerve

Provocative Testing of the Elbow and Hand

• Tinel’s sign– Maneuver = tap over the

carpal tunnel area (hand) or tap ulnar notch between olecranon process and medical epicondyle (elbow)

– Positive result (pain, tingling or electric sensation in hand) = carpal tunnel syndrome, median nerve in hand or ulnar nerve compromise in elbow

Case Studies

• MRI case study– Terminology

• T1 and T2 weighting

– What to look for in the report

• Electromyelogram case study– How they are done– What to look for in the

report

References

• http://.bledsoebrace.com/education/cp030012.htm

• http://bledsoebrace.com/products/products.htm

• http://www.fpnotebook.com/ORT55.htm

• http://orthoinfo.aaos.org

References

• Karen Muller, MPT, Journal of Orthopaedic & Sports Physical Therapy, 2000;30(3): 138-142

• The Physician and Sports Medicine: Patellofemoral pain

• mmg.Sechrest.com• www.kneeguru.co.uk• Taylor, S., P.T., “Diagnosis, Management and

Treatment of Knee Disorders: The Extensor Mechanism”, PowerPoint Presentation, New England Baptist Hospital, 2001.