Evaluation of the Knee and Shoulder
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1 Evaluation of the Knee and Shoulder Karen J. Boselli, MD Northeast Regional Nurse Practitioner Conference May 2018
2 Knee Overview History Examination Top 5 diagnoses When to image When to refer
3 Pain most common presenting complaint» Duration and location» Quality» Exacerbating & alleviating factors Any previous treatment» NSAIDs, ice, activity modification History of trauma Knee Evaluation History» Mechanism of injury is important
4 Inspection Knee Evaluation Physical Exam» Alignment varus or valgus» Ecchymosis» Effusion» Erythema or warmth» Deformity
5 Inspection Knee Evaluation Physical Exam» Sweep test for effusion
6 Palpation Knee Evaluation Physical Exam» Point tenderness» Patella» Quadriceps and patellar tendon» Joint lines medial and lateral
7 Range of motion Knee Evaluation Physical Exam» Only one plane of motion» Normal ROM 0 to » Varies based on habitus» Compare to contralateral knee» Feel for crepitus» Check hip ROM, consider referred pain
8 Special Tests» Patella grind» Straight leg raise» McMurray» Lachman» Valgus stress Knee Evaluation Physical Exam
9 Special Tests» Patella grind Knee Evaluation Physical Exam
10 Special Tests» Straight leg raise Knee Evaluation Physical Exam
11 Special Tests» McMurray Knee Evaluation Physical Exam
12 Special Tests» Lachman Knee Evaluation Physical Exam
13 Special Tests» Lachman Knee Evaluation Physical Exam
14 Special Tests» Valgus stress Knee Evaluation Physical Exam
15 Osteoarthritis Patellofemoral pain Meniscus tear ACL tear MCL tear Knee Evaluation Common Diagnoses
16 History Examination Special Tests When to image When to refer Knee Evaluation Common Diagnoses
17 History Knee Evaluation Osteoarthritis» Insidious onset of pain» Achy or sharp, localized or diffuse» Can be better or worse with activity» Limited range of motion
18 Examination Knee Evaluation Osteoarthritis» Alignment may be varus or valgus» Effusion common» Limited ROM in flexion or extension» Crepitus» Joint line tenderness» No special tests needed
19 Knee Evaluation Osteoarthritis When to image and refer» Plain films always first!» Rarely requires MRI to diagnose and treat» Refer after failure of conservative treatment including NSAIDs, therapy, +/- injection» Start weight loss process if indicated
20 History Knee Evaluation Patellofemoral Pain» Insidious onset» Deep anterior knee pain, may be diffuse» Sharp or achy» Worse with running, inclines, declines, stairs» Better with rest» But worse with prolonged sitting and driving
21 Examination Knee Evaluation Patellofemoral Pain» Alignment normal» Rare effusion» Full ROM but may have crepitus» Tender at medial and lateral patella» Positive patella grind test
22 Knee Evaluation Patellofemoral Pain When to image and refer» Consider plain films +/- but can manage without» Rarely if ever requires MRI» Refer after failure of NSAIDs and trial of PT
23 History Knee Evaluation Meniscus Tear» May be insidious in onset or associated w/ trauma» Often sharp pain and may be mechanical» Localized to joint line» Pain with side to side movements, pivoting, twisting» Swelling» Worse with activity and better with rest
24 Examination Knee Evaluation Meniscus Tear» Alignment normal» Effusion common but not always» Flexion may be limited due to pain» Point tender at joint line (medial or lateral)» Positive McMurray test but not always!
25 Knee Evaluation Meniscus Tear When to image and refer» Start with plain films to rule out OA» If normal and high suspicion consider MRI» Also reasonable to wait on MRI until after trial of conservative treatment depending on patient» Refer for positive MRI» Or lack of response to conservative care
26 History Knee Evaluation ACL Tear» Acute onset» Sudden pop, immediate swelling, difficulty WB» Mechanism usually twist on planted foot» Diffuse significant pain» Limited mobility» Knee feels unstable, like it will hyperextend
27 Examination Knee Evaluation ACL Tear» Large effusion (hemarthrosis)» Motion limited due to pain in flexion and extension» Joint line tenderness may be meniscus» Lachman test» Assess valgus stability for concomitant MCL» Difficult to assess acutely in painful situation
28 Knee Evaluation ACL Tear When to image and refer» Positive Lachman = MRI» High suspicion but equivocal exam = MRI» Refer for positive MRI when complete ACL tear» In the meantime knee immobilizer, crutches, WBAT
29 History Knee Evaluation MCL Tear» Sudden onset of pain» Medial knee» Associated with valgus force» Swelling delayed in onset» Limited ROM common complaint» Difficulty WB in some, feels unstable
30 Examination Knee Evaluation MCL Tear» Alignment normal» Some show small effusion» May have medial soft tissue swelling» Tender at medial joint line, epicondyle» Motion limited with flexion and extension» Valgus stress test positive for pain or instability
31 Knee Evaluation MCL Tear When to image and refer» Gross instability with valgus stress = MRI» Pain with valgus stress but no instability = no MRI» Most should be referred for management, even low grade, especially to determine timeline for return to sport
32 Knee Evaluation Questions
33 Shoulder Overview History Examination Top 5 (or 6!) diagnoses When to image When to refer
34 Pain usually presenting complaint» Duration, location, quality» Exacerbating & alleviating factors» Night pain very common Previous treatment» NSAIDs, ice, rest or activity modification History of trauma Loss of function Shoulder Evaluation History
35 Shoulder Evaluation Exam Inspection» Deformity» Swelling» Ecchymosis» Atrophy
36 Palpation» Bicipital groove» AC joint» Greater tuberosity» Joint line» Periscapular Shoulder Evaluation Exam
37 Range of motion Shoulder Evaluation Exam» More complicated because multiple planes» Flexion (elevation)» External rotation» Internal rotation» Always compare to contralateral side» Passive versus active motion
38 ROM» Flexion (elevation) Shoulder Evaluation Exam
39 ROM» External rotation Shoulder Evaluation Exam
40 ROM» Internal rotation Shoulder Evaluation Exam
41 Special Tests» Neer» Hawkins» Empty can» Belly press» Cross body» Apprehension» O Brien s» Speed s Shoulder Evaluation Exam
42 Special tests for impingement» Neer» Hawkins Shoulder Evaluation Exam
43 Special tests for rotator cuff tear» Neer» Hawkins» Empty can» Belly press Shoulder Evaluation Exam
44 Special tests for AC joint» Cross body adduction Shoulder Evaluation Exam
45 Shoulder Evaluation Exam Special tests for instability» Apprehension and relocation
46 Special tests for biceps and labrum» Speed s» O Brien s Shoulder Evaluation Exam
47 Special tests for biceps and labrum» Speed s» O Brien s Shoulder Evaluation Exam
48 Shoulder Evaluation Common Diagnoses Impingement (+/- rotator cuff tendinitis) Rotator cuff tear Osteoarthritis Adhesive capsulitis Instability Labral tear
49 History Examination Special Tests When to image When to refer Shoulder Evaluation Common Diagnoses
50 History Shoulder Evaluation Impingement» Insidious onset» Achy at rest, positional with movement» Pain with internal rotation, extension» Lateral shoulder into lateral arm» Less frequent night pain
51 Examination Shoulder Evaluation Impingement» Tender at greater tuberosity and bursa» ROM normally near full» Painful internal rotation» Positive Neer and Hawkins test
52 Shoulder Evaluation Impingement When to image and refer» Plain films consideration before or after treatment» MRI rarely indicated unless failure to respond» Start therapy, NSAIDs, +/- subacromial injection» Refer if failure to respond
53 History Shoulder Evaluation Rotator Cuff Tear» Traumatic versus insidious» Deep lateral arm pain, radiates to elbow» Night pain very common» Difficulty with overhead activities» Subjective weakness» Mechanical symptoms
54 Examination Shoulder Evaluation Rotator Cuff Tear» Tender at greater tuberosity» AROM may be limited in all planes» PROM usually well preserved» Crepitus with ROM» Rotator cuff weakness» Positive Neer, Hawkins, Empty Can
55 Shoulder Evaluation Rotator Cuff Tear When to image and refer» If high suspicion for acute tear check MRI» Degenerative tears in older patients are common and MRI not always necessary (consider referral 1 st )» Refer for acute tears in younger patients» Decision-making is complex and based on multiple factors when in doubt refer to specialist
56 History Shoulder Evaluation Osteoarthritis» Insidious onset» Achy pain deep in shoulder» Mechanical symptoms» Stiffness and limited mobility
57 Examination Shoulder Evaluation Osteoarthritis» Tender along anterior joint line» Limited AROM and PROM» Most pronounced with ER» Crepitus with motion» Good rotator cuff strength» No special tests
58 Shoulder Evaluation Osteoarthritis When to image and refer» Plain films will make the diagnosis» Reasonable to start trial of NSAIDs +/- therapy before referral to specialist
59 History Shoulder Evaluation Adhesive Capsulitis» Insidious onset, may be remote history of trauma» Severe pain» Achy at rest, sharp with sudden movement» Night pain debilitating» Deep shoulder with radiation to elbow» Pain at first, ultimately worsening stiffness
60 Examination Shoulder Evaluation Adhesive Capsulitis» Tender along joint line» Limited AROM and PROM» Usually most pronounced with IR» Pain with terminal ROM» Strength testing may be limited by pain» No special tests
61 Shoulder Evaluation Adhesive Capsulitis When to image and refer» Plain films will distinguish from OA» MRI rarely if ever indicated» Consider trial of PT and NSAIDs» Severe cases often require referral and consideration of glenohumeral injection
62 History Shoulder Evaluation Instability and Labral Tear» Acute onset» Frank dislocation event in some» Direct blow to the shoulder in some» Deep pain, intermittent in nature» Sense of instability» May have mechanical symptoms
63 Examination Shoulder Evaluation Instability and Labral Tear» Often no tenderness» Full range of motion in most» Well preserved strength» Positive apprehension and relocation» Positive O Brien and Speed
64 Shoulder Evaluation Instability and Labral Tear When to image and refer» Plain films first» Start with PT prior to MRI in most cases» If MRI ordered should be an arthrogram!» Refer if recurrent instability, or continued pain from labral tear with failure of conservative treatment
65 Knee and Shoulder Evaluation Questions
66 THANK YOU
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