Taming the Musculoskeletal Exam: İSí, se puede!

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1 Taming the Musculoskeletal Exam: İSí, se puede! Ronald H. Labuguen, MD UCSF Department of Family and Community Medicine NP/PA/CNM Professional Practice Conference San Francisco Department of Public Health October 17, 2013

2 Objectives 1. To learn principles of examining patients with common joint problems 2. To learn common clinical scenarios for common musculoskeletal problems 3. To learn how to approach diagnosis and treatment of common musculoskeletal problems in primary care and urgent care settings

3 Objectives 4. To review elements of the physical examination of the shoulder, elbow, hand/wrist, hip, knee, ankle, and foot 5. To develop a systematic physical examination of the shoulder and knee

4 Principles: Approaching Joint Problems Learn typical clinical scenarios for common joint problems: History Chief complaints Timing/duration of symptoms Typical findings

5 Principles: Approaching Joint Problems Know functional anatomy, physical examination techniques for each joint Initial and subsequent treatment Red flags: need for referral or immediate treatment

6 Common Joints Upper extremity: Hand/wrist Elbow Shoulder Lower extremity: Hip Knee Ankle Foot

7 Case 1: Hand/Wrist 43 yo man c/o hand numbness

8 Carpal Tunnel Syndrome Compression of the median nerve through the carpal tunnel Inflammatory Overuse Paresthesias Worse at night, upon awakening

9 Carpal Tunnel Syndrome Neuro exam: sensation, strength Know median nerve distribution and innervation Thenar atrophy

10 Carpal Tunnel Syndrome Tinel s sign Phalen s sign Flick sign

11 Carpal Tunnel Syndrome NSAID s Volar (cock-up) wrist splint Steroid injection Surgery

13 Other Common Hand and Wrist Arthritis Problems De Quervain tenosynovitis Fall on outstretched hand (FOOSH) Fractures: phalanges, metacarpals, scaphoid (navicular), distal radius Ganglion cyst Trigger finger Mallet finger

17 43 yo man c/o pain in elbow Case 2: Elbow

18 Lateral Epicondylitis Tears/microtears in tendons originating at lateral epicondyle Overuse of forearm muscles Inflammatory Constant symptoms Aching night pain referring to humerus

19 Lateral Epicondylitis Pain on palpation just distal to lateral epicondyle Pain with resisted Active extension (passive flexion) of wrist Supination 3 rd finger extension

20 Lateral Epicondylitis NSAIDs Tennis elbow brace Steroid injection Surgery

21 Other Common Elbow Problems Arthritis Fractures: distal humerus, radial head Medial epicondylitis Olecranon bursitis Nerve compression syndromes Rupture of distal biceps tendon

22 Radial Head Fracture Most common fracture in adults FOOSH, axial load to distal radius radial head Ballotable hemarthrosis

23 Lateral epicondyle Radial head

25 43 yo man c/o right shoulder pain Case 3: Shoulder

26 Impingement Syndrome Inflammation of subacromial bursa and rotator cuff tendons Overuse Continuum of pathology

27 Impingement Syndrome Anterior and lateral shoulder pain Gradual onset Overhead activity Worse at night Can t sleep on affected side

28 Impingement Syndrome Palpation Greater tuberosity Subacromial bursa Signs: Neer Hawkins Supraspinatus impingement

29 Impingement Syndrome NSAIDs Rest Stretching & strengthening Steroid injection Surgery

30 Other Common Shoulder Problems Acromioclavicular arthritis/injury Arthritis Fractures of the clavicle, humerus, scapula Rotator cuff tear Biceps tendon rupture Shoulder instability Superior Labrum Anterior-to-Posterior (SLAP) lesions Thoracic outlet syndrome

38 Inspection Range of Motion Palpation Shoulder Exam

39 Shoulder Exam Special tests Impingement signs: Neer, Hawkins Strength testing: Supraspinatus, external/internal rotation O Brien s test (SLAP lesion) Apprehension sign (glenohumeral instability)

40 63 yo man c/o thigh pain Case 4: Hip

41 Osteoarthritis of the Hip Degenerative Loss of articular cartilage Primary or secondary Trauma Osteonecrosis Previous joint infections

42 Osteoarthritis of the Hip Gradual onset of anterior thigh or groin pain Buttock or lateral thigh pain Referred pain to distal thigh, knee Initially only with activity; more constant later Decreased ROM Limp, stiffness

43 Osteoarthritis of the Hip ROM: loss of internal rotation first Fixed external rotation and flexion contracture Antalgic gait Abductor lurch

44 Osteoarthritis of the Hip X-rays: Joint space narrowing Osteophytes Subchondral cysts Subchondral sclerosis

45 Osteoarthritis of the Hip Pain/antiinflammatory medication Activity modification Assistive device NWB exercise Steroid injections Surgery

46 Other Common Hip Problems Osteonecrosis of the hip Snapping hip Hip strains Trochanteric bursitis Fractures: pelvis, proximal femur

47 34 yo woman c/o knee pain Case 5: Knee

Management of Patellofemoral Pain Syndrome SAMEER DIXIT, M.D., AND JOHN P. DIFIORI, M.D., UNIVERSITY OF CALIFORNIA, LOS ANGELES, LOS ANGELES, CALIFORNIA MONIQUE BURTON, M.D., UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON BRANDON MINES, M.

48 Management of Patellofemoral Pain Syndrome SAMEER DIXIT, M.D., AND JOHN P. DIFIORI, M.D., UNIVERSITY OF CALIFORNIA, LOS ANGELES, LOS ANGELES, CALIFORNIA MONIQUE BURTON, M.D., UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON BRANDON MINES, M.D., EMORY UNIVERSITY, ATLANTA, GEORGIA Am Fam Physician 2007;75: , 204. Copyright 2007 American Academy of Family Physicians

49 Patellofemoral Pain Overuse/ overloading Diffuse, aching anterior knee pain Sometimes caused by patellar malalignment

50 Patellofemoral Pain Feels like knee catches or might give way Worst when Running Going up/down stairs Kneeling, squatting Getting up after sitting for a while

51 Patellofemoral Pain Weight bearing stance and gait: Patellae point to each other Knock-knees Foot pronation

52 Patellofemoral Pain Excessive femoral anteversion (hip internal rotation > external rotation by 30 +) J sign (patella moves laterally >1 cm near full extension) Tight hamstrings, quadriceps Patellar grind test Patellar apprehension test

53 Lateral patellar tracking ("J" sign). As the knee is extended from 90 degrees flexion (A) to full extension (B), the patella demonstrates an abnormal path, deviating laterally at full extension.

Patellar mobility testing. Depicted is medial glide testing performed on the right knee. The patella is grasped in the resting position (A), then translated medially (B).

54 Patellar mobility testing. Depicted is medial glide testing performed on the right knee. The patella is grasped in the resting position (A), then translated medially (B). The extent of displacement is described in relation to the width of the patella and measured in quadrants (C). Displacement of less than one quadrant medially indicates tightness of the lateral structures. Displacement of more than three quadrants is considered hypermobile.

55 Patellar tilt test. This test assesses for tightness of the lateral structures. The knee is extended and the patella is grasped between the thumb and forefinger. The medial aspect of the patella is then compressed posteriorly while the lateral aspect is elevated. If the lateral aspect of the patella is fixed and cannot be raised to at least the horizontal position (0 degrees), the test is positive and indicates tight lateral structures. This also can be seen in patients with patellofemoral osteoarthritis.

Patellar grind (or inhibition) test. While the patient is in the supine position with the knee extended, the examiner displaces the patella inferiorly into the trochlear groove (pictured).

56 Patellar grind (or inhibition) test. While the patient is in the supine position with the knee extended, the examiner displaces the patella inferiorly into the trochlear groove (pictured). The patient is then asked to contract the quadriceps while the examiner continues to palpate the patella and provides gentle resistance to superior movement of the patella. The test is positive if pain is produced, although comparison to the contralateral knee is needed to interpret the result.

57 Patellofemoral Pain X-rays Rule out malalignment, arthritis

58 Patellofemoral Pain Relative rest Quadriceps strengthening Increase flexibility in quadriceps and hamstrings Brace Analgesics Surgery

59 The knee is the worst-designed joint in the human body.

60 Other Common Knee Problems Ligament injuries: ACL, MCL, LCL, PCL Arthritis Bursitis (prepatellar, pes anserine) Iliotibial band syndrome Meniscal tear Patellar/quadriceps tendinitis Popliteal (Baker s) cyst

61 Inspection Palpation Special tests Ligament Meniscus Knee Exam

62 Knee Exam ACL Lachman s PCL Posterior drawer, sag sign MCL valgus stress LCL varus stress Meniscus McMurray s circumduction, Apley s grind, Thessaly

63 Knee X-ray Tips Ottawa Ankle Rules Age 55 Unable to bear weight 4 steps Unable to flex to 90 Isolated tenderness of patella Tenderness at fibular head Weight bearing films for dx of OA

64 RAZIB KHAUND, M.D., SHARON H. FLYNN, M.D., Iliotibial Band Syndrome: A Common Source of Knee Pain Am Fam Physician 2005;71:

65 Ober's test. The patient lies down with the unaffected side down and the unaffected hip and knee at a 90- degree angle. If the iliotibial band is tight, the patient will have difficulty adducting the leg beyond the midline and may experience pain at the lateral knee (arrows).

66 Case 6: Ankle 43 yo man c/o acute ankle injury and pain

67 Inversion injury Stretching or tearing of lateral ligaments Ankle Sprain

$, avulsion fracture at base of 5 th metatarsal) Distal or proximal fibula fracture$

68 Ankle Sprain Watch out! Fractures (e.g., avulsion fracture at base of 5 th metatarsal) Distal or proximal fibula fracture Peroneal tendon tear or subluxation Lisfranc injury

69 Ottawa Ankle Rules

70 Ankle Sprain NSAIDs, RICE?Ambulatory cast WBAT Early mobilization Rehab: Strengthening Proprioception Agility Endurance training

71 Other Common Ankle Problems Achilles tendonitis or rupture Chronic lateral ankle pain Fractures

72 Case 7: Foot 43 yo man c/o chronic heel pain

73 Microtrauma of the plantar fascia at the insertion in the medial tuberosity of the calcaneus Overuse Inflammatory More common in women, overweight Plantar Fasciitis

74 Insidious onset Worst when arising from resting position, prolonged standing/walking Plantar Fasciitis

75 Focal pain and tenderness over medial calcaneal tuberosity and 1-2 cm distally along plantar fascia Pain with passive dorsiflexion of toes Achilles tendon tightness Plantar Fasciitis

76 Stretching Anti-inflammatory treatments Orthotics (heel pad) Plantar Fasciitis

77 Tension night splint Plantar Fasciitis

78 Steroid injection Surgery Plantar Fasciitis

79 Other Common Foot Problems Bunion Fractures Interdigital (Morton) neuroma Metatarsalgia Posterior heel pain Tarsal tunnel syndrome Turf toe (1 st MT joint sprain)

80 Summary: See? İse puede! Joint complaints are commonly seen in family medicine Learn the functional anatomy of the joints and how it relates to the physical exam Learn typical historical scenarios for common joint problems and the workup associated with each

81 References Greene WB, ed. Essentials of Musculoskeletal Care, 3rd ed. Rosemont (Ill.): American Academy of Orthopaedic Surgeons, American Family Physician, various articles. Joseph Moore, MD, Elbow, Wrist and Hand Injuries, AAFP 2013 Ann. Sci. Assembly.

The examination of the painful knee. Maja K Artandi, MD, FACP Clinical Associate Professor of Medicine Stanford University

The examination of the painful knee Maja K Artandi, MD, FACP Clinical Associate Professor of Medicine Stanford University Objectives of the talk By the end of this talk you will know The important anatomy