mastering the musculoskeletal exam
TRANSCRIPT
Mastering the Musculoskeletal Exam
UCSF Essentials of Women’s HealthJuly 7, 2016
Carlin Senter, M.D.Henry Crevensten, M.D.
I have nothingto disclose
Outline
• Knee exam
• Shoulder examKnee Anatomy
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
There are 4 main ligaments in the knee
Meniscus
Knee examMusculoskeletal work‐up
•History
• Inspection•Palpation
•Range of motion
•Other Tests
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.
Palpation of joint lineseated or supine
http://www.rheumors.com/kneeexam/palpation.html
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
Other Tests: Lachman to evaluate ACLSensitivity 75‐100% Specificity 95‐100%
Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.
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.
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
Shoulder anatomy
Underlying 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
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 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
Shoulder examination
• Inspection– Patient in gown
• Palpation
• ROM
• Strength– Supra
– Infra and teresminor
– Subscapularis
• Other tests
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.
Shoulder examination
• Inspection
• Palpation• ROM
• Strength– Supraspinatus
– Infraspinatus & Teres minor
– Subscapularis
• Other tests
Range of motion
Abduction
Flexion
Range of motion
External rotation
Internal rotation
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
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’s
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.
Exam practice:pain provocation tests in RCD
• Hawkins impingement sign
• Neers impingement sign
• Painful arc (rotator cuff dz)
2
Pain & Strength test: Supraspinatus = abduction
Empty can(aka Jobe’s)
Supraspinatus
71% sensitivity41% specificity for rotator cuff disease. (+) LR 1.3
Pain/strength test: Drop arm test
JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.
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
Strength test:External rotation lag test
Positive LR 7.2,Negative LR 0.57 for full thickness rotator cuff tear
JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.
Pain & Strength test:Subscapularis = internal rotation lag test
JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.
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)
3
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%
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)
4
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