SIT DOWN, STAND UP, BEND OVER

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1 SIT DOWN, STAND UP, BEND OVER A Review of the Musculoskeletal Physical Examination Larry Collins, MPAS, PA-C, ATC, DFAAPA Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine

2 History You cannot overemphasize the importance of a thorough and detailed history. In most cases if you ask the appropriate questions you will have a very good idea of the diagnosis before you ever examine the patient. Questions must include: Onset Mechanism of injury Quality of symptoms Persistence of symptoms Previous injuries Treatment to date ADL s Work activities Precipitating factors Alleviating factors Mechanical symptoms Training routines

3 Physical Examination You should strive to perform a detailed and systematic physical examination that follows a similar pattern each time you evaluate a patient. Knowing appropriate anatomy is paramount to properly evaluating your patients. A typical routine might be: Inspection Palpation R.O.M. Strength Stability Special tests Don t forget: Joint above/below Neurological Vascular Referred pain

4 Anatomy - Vertebral 7 Cervical vertebrae 12 Thoracic vertebrae 5 Lumbar vertebrae Sacrum Column

5 Anatomy Vertebral column Anterior Segment - weight bearing Vertebral Bodies Intervertebral Disc Posterior Segment - regulates motion and protects spinal cord and nerve roots Facet joints Thoracic horizontal, allowing rotation, Pedicles side-bending Lumbar vertical, allowing flexion/extension Neural Foramina Spinous processes Muscular insertions Spinal Cord and nerve roots

6 Anatomy Ligaments Prevent extremes of movement Anterior and Posterior Longitudinal Ligaments Posterior Ligament narrows near sacrum Muscles Superficial Erector Spinae Deep Multifidis Interspinalis Intertransversarii Psoas Iliacus Abdominals

7 Anatomy - Nerves An unfortunate patient is diagnosed with having a lateral disc herniation at the C 56 and L 45 levels. Which of the following dermatomes would you expect to be affected? a) C5 and L4 b) C6 and L5 c) C5 and L5 d) C6 and L4

8 Anatomy Nerve Roots

9 Anatomy - Nerves

10 Cervical Spine Palpation Spinous process Paravertebral muscles Range of Motion Flexion Extension Rotation Lateral bending Sensation C2 C3 C4 C5 C6 C7 C8 T1 Strength C5 C6 C7 C8 T1 Reflexes C5 C6 C7 Special Tests Spurling s Valsalva Compression/Distraction Vertebral Artery Test

11 Cervical Sensory Reflexes Motor

12 Lumbar Spine Palpation Spinous process Paravertebral muscles Range of Motion Flexion Extension Rotation Lateral bending Sensation L1 L2 L3 L4 L5 S1 S2-5 Strength T12 L3 L2 L4 L4 L5 S1 Reflexes L4 S1 Babinski Special Tests Straight leg raise Gaenslen s Pelvic rock One-leg hyperextension Patrick (Fabere) Hoover s Kernig/ Brudzinkski

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14 Examination Of Patient With Low Back Pain

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18 Shoulder Anatomy

19 Shoulder Anatomy Ligaments

20 Shoulder Anatomy Muscles

21 Shoulder Exam Inspection Atrophy Scapular dyskinesis ROM Active vs. passive Strength Rotator cuff Special Tests Impingement Stability

22 Dr. Lintner, MD. emedwebs, Inc. - TOS - Houston TX Scapular Dyskinesis

23 Atrophy

24 Shoulder Palpation Bones SC Clavicle AC Scapula Coracoid process Greater tubercle humerus Biceps groove

25 Shoulder Range of Motion - active/passive Shoulder shrug symmetry Forward flexion 180 degrees Extension 50 degrees Abduction 180 degrees Adduction 50 degrees Internal rotation 90 degrees External rotation 90 degrees

26 Range of Motion Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30:

27 Shoulder Strength Shoulder shrug - CN XI Forward flexion Abduction Internal/external rotation

28 Strength Supraspinatus abduction Infraspinatus external rotation Teres Minor external rotation Subscapularis internal rotation

29 Rotator Cuff Exam Empty can supraspinatus External rotation infraspinatus Hawkins impingement test Apprehension test Murrell GAC and Walton J. Clinical diagnosis of rotator cuff tears. The Lancet, 357 (2001):

30 Special Tests Neer s test Supraspinatus Impingement

31 Stability Exam Sulcus sign Apprehension test Apprehension-relocation test Anterior/posterior drawer test

32 Generalized Laxity

33 SLAP Exam (Superior Labrum Anterior Posterior) Compression rotation test Obrien s test Biceps tension test (speed test)

34 Nerve Injuries Suprascapular Nerve

35 Nerve Injuries Long Thoracic Nerve

36 Elbow Carrying Angle Surface Anatomy Medial epicondyle Lateral epicondyle Olecranon Ulnar groove Radial head

37 Elbow ROM Flexion, extension, pronation, supination Manual muscle strength Special Tests Varus/Valgus Stress Lateral Epicondylitis Medial Epicondylitis Tinel's Sign

38 Wrist, Hand and Fingers Surface Anatomy Ulnar Styloid Scaphoid Pisiform Hook of hamate MCP joints IP joints

39 Wrist, Hand and Fingers ROM Flexion, extension, pronation, supination, radial/ulnar deviation, excursion (MC rotation) Manual Muscle Tests Special Tests Pinch Grip Finkelstein Test Phalen's Tinel Allen's

40 Hip Injuries to hip & pelvis are often frustrating Evaluation is difficult May involve variety of soft tissues and bones May be acute, sub-acute or chronic Large differential diagnosis Understand mechanism, natural history & physical findings Accurate diagnosis is essential

41 Hip Inspection Palpation ROM (passive/active) Lumbar spine Hip Flexion 120 Extension 10 Abduction 40 Adduction 30 Internal rotation 50 External rotation 35 Knee Strength Flexors Extensors Abductors Adductors Hamstrings Quadriceps

42 Hip Neurovascular Sensation Pulses DTR Specific tests Trendelenburg Ober test Patrick s/fabere test Gaenslen's test Compression/Distraction Hernia/testicular

43 Knee Anatomy

44 Key factors in making diagnosis Mechanism of injury Onset of swelling Ability to bear weight Mechanical symptoms Instability Knee Pre-existing conditions

45 Knee Inspection Lacerations/Contusions Alignment/Deformity Effusion/Hemarthrosis Gait Palpation Joint line pain Meniscus tear Palpable defects Quadriceps tendon, Patella ligament, Patella fracture Alignment

46 ROM Knee (0-140 ) Strength Quadriceps Straight leg raise Extensor lag Hamstrings Neurovascular Knee

47 Physical Examination Special tests Meniscus Joint line pain Squat Steinmann McMurray Apley Thessaly Hip

48 Differential Diagnosis Acute hemarthrosis Peripheral meniscus tear ACL/PCL tear Dislocation Patella, knee Fractures Bleeding disorders Coumadin PVNS vs. Prepatellar Bursitis

49 Physical Examination Ligaments Injured Ligament Key Test Secondary Test ACL Lachman Pivot Shift MCL Valgus laxity at 30 Valgus laxity at 0 PCL Posterior drawer at 90 Posterior sag at 90 LCL Varus laxity at 30 Varus laxity at 0 Posterolateral corner ER at 30 Posterior drawer at 30

50 Ligament Injuries - ACL Examination Hemarthrosis Contralateral side Anterior drawer Lachman Pivot Shift Difficult to reproduce Must be relaxed

51 Ligament Injuries MCL Examination Pain to palpation Little or no effusion/hemarthrosis Valgus instability at 30 0 ACL) In child consider growth plate injury

52 Examination Ligament Injuries PCL Hemarthrosis Posterior drawer Posterior sag Quadriceps active test

53 Extensor Mechanism Injuries Commonly misdiagnosed Anatomy Quadriceps muscle quadriceps tendon patella patella tendon

54 Extensor Mechanism Injuries History Patella tendon Younger patient Athletics Quadriceps tendon Older patient Systemic disease Vigorous eccentric quadriceps contraction Unable to straighten leg Fluoroquinolones (Cipro, Levaquin, etc.)

55 Extensor Mechanism Injuries Examination Palpable defect Unable to do straight leg raise Extensor lag Hemarthrosis Imaging Radiographs Patella alta Peds sleeve fracture, tibial tubercle avulsion MRI/Ultrasound

56 Anterior Knee Pain Multifaceted Mal-alignment Weakness (VMO, hip extensors) Decreased flexibility (quad, calf Neuromuscular adaptations (increased reflex arc, decreased response times) Generalized joint laxity

57 Q angle Pronated Foot

58 PFPS Exam Observe and palpate tracking through active flexion and extension Crepitus most noticeable with active motion Patellar compression may increase pain Translate patella laterally in extension and attempt to flex knee Assess general laxity

59 Popliteal Cyst Exam Between semimembranosus and medial head gastrocnemius Most visible and palpable with the knee extended (standing) Palpate for size, consistency, and tenderness Examine the knee for signs of derangement (i.e. meniscal tears)

60 Popliteal Cyst Differential Diagnosis Deep vein thrombosis (ultrasound) Exertional compartment syndrome (compartment pressure measurement) Inflammatory arthritis (serologic tests) Medial gastrocnemius strain (H & P) Soft-tissue tumor (MRI) Superficial phlebitis (H & P, US)

61 Ankle Anatomy

62 Ankle Anatomy

63 Ankle Inspection Pronation, pes planus Palpation Medial malleolus, lateral malleolus, navicular, 5 th metatarsal ATFL, deltoid, peroneal, posterior tibialis ROM / Strength Dorsiflexion, plantarflexion, inversion, eversion, subtalar motion

64 Inversion Injuries With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces

65 Ankle Stability Tests Anterior drawer test Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point

66 Talar tilt test Performed to determine extent of inversion or eversion injuries With foot at 90 degrees, calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments If the calcaneus is everted, the deltoid ligament is tested

67 Etiology Eversion Ankle Sprains Bony protection and ligament strength decreases likelihood of injury Eversion force resulting in damage to deltoid and possibly fx of the fibula Deltoid can also be impinged and contused with inversion sprains Represent <5-10% of all ankle sprains

68 Syndesmosis Sprain High Ankle Sprain Mechanism of injury External rotation force Turf sports Player prone and force applied to back of leg Fixed, planted foot with cutting or blow to leg Examination Pain at distal syndesmosis Squeeze test Pain at syndesmosis with external rotation of foot Athlete walks on toes Diagnostic Studies X-ray Stress test MRI

69 4 Ligaments

70 Ottawa Foot & Ankle Rules An ankle x-ray is required only if there is any pain in malleolar zone and any of these findings: Bone tenderness at A Bone tenderness at B Inability to weight bear both immediately and in the ED A foot x-ray is required if there is any pain in the midfoot zone and any of these findings: Bone tenderness at C Bone tenderness at D Inability to weight bear both immediately and in the ED

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72 Questions? A Review of the Musculoskeletal Physical Examination Larry Collins, MPAS, PA-C, ATC, DFAAPA Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine Lcollins@Health.usf.edu

73 Thank You