Examining the Physical Exam

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Overview Examining the Physical Exam How to Make Yours Better A

California, San Francisco Primary Care Medicine: Update 2017

Considering the differential diagnosis Physical exam confirm the

The patient will tell you what the problem is Age

1 Overview Examining the Physical Exam How to Make Yours Better A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco Primary Care Medicine: Update 2017 Quick approach to MSK problems History what does it mean? Considering the differential diagnosis Physical exam confirm the diagnosis Is the patient? The patient will tell you what the problem is Age Occupation/Activity Recreational, competitive, or elite Handedness Past medical history Family history Manage patient expectations 1

Age factor Children Tendons and ligaments relatively stronger than epiphyseal plate Insertional

death; repair affected is the Chief Complaint? The BIG THREE 1. Pain 2. Instability 3.

2 Age factor Children Tendons and ligaments relatively stronger than epiphyseal plate Insertional overuse injuries (OSD, SLJ, Sever s) Elderly Decreased flexibility Apoptosis programmed cell death; repair affected is the Chief Complaint? The BIG THREE 1. Pain 2. Instability 3. Dysfunction Other complaints: swelling, numbness and tingling, decreased performance Intra-articular vs. extra-articular Consider onset of swelling 1) Immediate - minutes 2) In 24 hours 3) Insidious - days Swelling Constant Sharp Greater load = greater pain (i.e. weightbearing) May have pressure features Bone Pain 2

Tendon Pain May be present at the start of an activity then warm-up Sore when the

Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD Acute Chronic

L i g a m e n t Anatomy and Biomechanics Ultimate Ligament Tension Failure ACL:

3 Tendon Pain May be present at the start of an activity then warm-up Sore when the muscle is used May occur in compensation for other structural problems near by Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD Acute Chronic Acute on Chronic Onset of injury? Mechanism of Injury? L i g a m e n t Anatomy and Biomechanics Ultimate Ligament Tension Failure ACL: 2200 N (Anterior) PCL: 2500 N (Posterior) MCL: 4000N (Valgus) LCL: 750N (Varus) Posteromedial Corner Posterolateral Corner 3

1700 N Butler, Clin Orthop, 1985 Sports = 2000+ N Think about structures in injured area Is the pain referred?

4 Biomechanical Studies is the injury located? Forces on the ACL/Graft Level Walking = 169 N Ascending Stairs = 67 N Descending Stairs = 445 N Morrison, Biomech, 1970 Morrison, Bio Eng,1968,1969 Normal Walking = 400 N Sharp Cutting = 1700 N Butler, Clin Orthop, 1985 Sports = N Think about structures in injured area Is the pain referred? The one-finger test Know your anatomy Red Flag Symptoms Severe disability Numbness and tingling Night pain Constitutional symptoms (fever, wt loss) Swelling with no injury Systemic illness Multiple joint injury Intrinsic Risk Factors Growth Anatomy Muscle/Tendon imbalance Illness Nutrition Conditioning Psychology Extrinsic Risk Factors Training Technique Footwear Surface Occupation TO PREVENT INJURIES!! 4

First Test - Physical Exam Physical exam Physical Exam LOOK Observation Swelling, Erythema, Atrophy, Deformity, Surgical Scars (SEADS) FEEL Palpate important structures MOVE Assess Range of Motion

e. weight bearing activity) Confirms or excludes the suspected diagnosis Tests are often non-specific Groups of tests can improve sensitivity and specificity Other physical exam Alignment Motor

5 First Test - Physical Exam Physical exam Physical Exam LOOK Observation Swelling, Erythema, Atrophy, Deformity, Surgical Scars (SEADS) FEEL Palpate important structures MOVE Assess Range of Motion Always check Neurovascular Status SPECIAL TESTS Provocative tests Reproduce patient s pain Stress tests Stress structures for instability (i.e. ligaments) Functional tests Assess functional movements (i.e. weight bearing activity) Confirms or excludes the suspected diagnosis Tests are often non-specific Groups of tests can improve sensitivity and specificity Other physical exam Alignment Motor strength Flexibility of agonists and antagonists Neurologic Check the joint above and the joint below THINK KINETIC CHAIN Case - Knee Swelling 22 year old Skier comes has twisting injury in her knee skiing. Develops immediate swelling after injury and has to be brought down by ski patrol 5

Surgical scars Bulge sign Milk medially, push laterally (Patellar tap) Feel

6 Look (Standing) Look (Supine) Alignment Ankles together Ankles apart On toes Walk Red flag can t do it Hop test SEADS Swelling Erythema Atrophy Deformity Surgical scars Bulge sign Milk medially, push laterally (Patellar tap) Feel Patella Tender over facets of patella Apprehension sign suggests possible instability Feel 6

Musculoskeletal Physical Examination, Mosby, 2006 * - denotes under anesthesia Special Tests ACL Lachman's test test at 20 Sens 81.8%, Spec 96.

7 Feel - Patellar mobility Feel Joint Line Special Tests ACL Lachman's test test at 20 Sens 81.8%, Spec 96.8% Anterior drawer test at 90 Sens 22-41%, Spec 97%* Pivot shift Sens %*, Spec 98%* Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 * - denotes under anesthesia Special Tests ACL Lachman's test test at 20 Sens 81.8%, Spec 96.8% Anterior drawer test at 90 Sens 22-41%, Spec 97%* Pivot shift Sens %*, Spec 98%* Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 * - denotes under anesthesia Drop Lachman test 7

Medial Collateral Ligament (MCL) Injury Physical Exam Tender medially over MCL (often proximally)

at 20 Sens = 86-96 % Malanga GA, Nadler SF.

Mechanism Fall directly on knee with foot plantarflexed Dashboard injury Symptoms Pain with

sign Sens 79%, Spec 100% Posterior drawer test Sens 90%, Spec 99% Rubenstein et al.

8 Medial Collateral Ligament (MCL) Injury Physical Exam Tender medially over MCL (often proximally) May lack ROM pseudolocking Valgus stress test Medial Collateral Ligament (MCL) Injury Physical Exam Tender medially over MCL (often proximally) May lack ROM pseudolocking Valgus stress test test at 20 Sens = % Malanga GA, Nadler SF. Musculoskeletal Physical Examination, Mosby, 2006 Posterior Cruciate Ligament (PCL) Injury Mechanism Fall directly on knee with foot plantarflexed Dashboard injury Symptoms Pain with activities Disability > Instability Posterior Cruciate Ligament (PCL) Injury Physical Exam Sag sign Sens 79%, Spec 100% Posterior drawer test Sens 90%, Spec 99% Rubenstein et al., Am J Sports Med, 1994; 22: X-ray- often non-diagnostic MRI is test of choice 8

Meniscus Tear Special Tests: Meniscus Fowler PJ, Lubliner JA.

Mechanism Occurs after twisting injury or deep squat Patient may not

Usually posterior aspects of joint line Swelling Test Sensitivity

2% Extension block 84.7% 43.75% McMurray Classic (Med Thud) 28.75% 95.

Modified McMurray Testing Thessaly Test Flex hip to 90 degrees Flex knee

the knee with rotations Courtesy of Keegan Duchicella MD Hold patient s

Twisting movement will reproduce pain from meniscal injury Repeat with 20

9 Meniscus Tear Special Tests: Meniscus Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): Mechanism Occurs after twisting injury or deep squat Patient may not recall specific injury Symptoms Catching Medial or lateral knee pain Usually posterior aspects of joint line Swelling Test Sensitivity Specificity Joint line tender 85.5% 29.4% Hyperflexion 50% 68.2% Extension block 84.7% 43.75% McMurray Classic (Med Thud) 28.75% 95.3% McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5% 80% Modified McMurray Testing Thessaly Test Flex hip to 90 degrees Flex knee Internally or externally rotate lower leg with rotation of knee Fully flex the knee with rotations Courtesy of Keegan Duchicella MD Hold patient s hands for support Patient bends knee to 5 while he/she twists on knee Twisting movement will reproduce pain from meniscal injury Repeat with 20 knee flexion Medial side: Sens 89%, Spec 97% Lateral side: Sens. 92%; Spec 96% Karachalios et al. J Bone Joint Surg Am, 2005; 87: Courtesy of Keegan Duchicella MD 9

Swelling/bruising laterally FEEL Point of maximal tenderness usually ATF MOVE Limited motion due to swelling Anterior talofibular ligament Calcaneo fibular ligament Special Tests Anterior Drawer Test

10 Ankle Injury Physical Exam 40 y.o. Male Tennis player suffers inversion injury to the ankle Symptoms Localized pain usually over the lateral aspect of the ankle Difficulty weight bearing, limping May feel unstable in the ankle LOOK Swelling/bruising laterally FEEL Point of maximal tenderness usually ATF MOVE Limited motion due to swelling Anterior talofibular ligament Calcaneo fibular ligament Special Tests Anterior Drawer Test Normal ~ 3 mm Foot in neutral position Fix tibia Draw calcaneus forward Tests ATF ligament Sens = 80% Spec = 74% PPV = 91% NPV = 52% van Dijk et al. J Bone Joint Surg-Br, 1996; 78B: Special Tests Anterior Drawer Test Normal ~ 3 mm Foot in neutral position Fix tibia Draw calcaneus forward Tests ATF ligament Sens = 80% Spec = 74% PPV = 91% NPV = 52% van Dijk et al. J Bone Joint Surg-Br, 1996; 78B:

Subtalar Tilt Test Subtalar Tilt test Foot in neutral position Fix tibia Invert or tilt calcaneus Tests Calcaneofibular ligament No

good end point 3 Drawer and tilt lax Pathology Mild stretch with no instability ATFL torn, CFL and PTFL intact ATFL and CFL

office (4 steps) Bone tenderness at the posterior edge of the medial or lateral malleolus (Obtain Ankle Series) Bone tenderness over

11 Subtalar Tilt Test Subtalar Tilt test Foot in neutral position Fix tibia Invert or tilt calcaneus Tests Calcaneofibular ligament No Sens / Spec Data Grade Grading Ankle Sprains Drawer/Tilt Test results 1 Drawer and tilt negative, but tender 2 Drawer lax, tilt with good end point 3 Drawer and tilt lax Pathology Mild stretch with no instability ATFL torn, CFL and PTFL intact ATFL and CFL injured/torn Functional Recovery in weeks Ottawa Ankle Rules Inability to weight bear immediately and in the emergency/ office (4 steps) Bone tenderness at the posterior edge of the medial or lateral malleolus (Obtain Ankle Series) Bone tenderness over the navicular or base of the fifth metatarsal (Obtain Foot Series) Sens = 97% Spec = 31-63% PPV = 20% NPV = 99% Am J Emerg Med 1998; 16:

$tibiofibular ligament R/O Proximal fibular fracture External Rotation Stress Test Fix tibia Foot in neutral Dorsiflex and$ externally rotate ankle No Sens/ Spec Data Kappa = 0.75 Alonso et al.

externally rotate ankle No Sens/ Spec Data Kappa = 0.75 Alonso et al.

Sports Phys Ther, 1998; 27: 276-284 Hold leg at mid calf level Squeeze tibia and fibula together Pain located over anterior

12 High Ankle Sprains Mechanism Dorsiflexion, eversion injury Disruption of the Syndesmotic ligaments Most commonly the anterior tibiofibular ligament R/O Proximal fibular fracture External Rotation Stress Test Fix tibia Foot in neutral Dorsiflex and externally rotate ankle No Sens/ Spec Data Kappa = 0.75 Alonso et al. J Orthop Sports Phys Ther, 1998; 27: External Rotation Stress Test Fix tibia Foot in neutral Dorsiflex and externally rotate ankle No Sens/ Spec Data Kappa = 0.75 Alonso et al. J Orthop Sports Phys Ther, 1998; 27: Hold leg at mid calf level Squeeze tibia and fibula together Pain located over anterior tibiofibular ligament area No Sens/ Spec Data Kappa = 0.50 Alonso et al. J Orthop Sports Phys Ther, 1998; 27: Squeeze test 12

Female track athlete has pain in back of calf running Pushing off, running, sprinting,

plantarflex Sens = 96 % Spec = 93 % Maffuli N.

13 Achilles Tendinopathy 28 y.o. Female track athlete has pain in back of calf running Pushing off, running, sprinting, jumping Hit in back of leg while sprinting Exam - Thompson s test Squeeze calf Foot should plantarflex Sens = 96 % Spec = 93 % Maffuli N. Am J Sport Med, 1998; 26: Basic P/E findings for tendinopathy 1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch Shoulder Impingement Syndrome Mechanism Impingement under acromion with flexion and internal rotation of the shoulder Rotator cuff, subacromial bursa and biceps tendon Impingement Symptoms Problems with: Overhead activities? Sleep? Putting on a jacket? 13

Shoulder Pain Differential Diagnosis Rotator cuff

tendinopathy Frozen shoulder (adhesive capsulitis)

radiculopathy SEADS Swelling Erythema Atrophy Deformity

Less common Spinal Accessory Nerve (trapezius) Dorsal

Pain may alter mechanics or vice versa Winging MOVE Range

14 Shoulder Pain Differential Diagnosis Rotator cuff tendinopathy Rotator cuff tears SLAP Lesion Calcific tendinopathy Frozen shoulder (adhesive capsulitis) Acromioclavicular joint problems Scapular weakness Cervical radiculopathy SEADS Swelling Erythema Atrophy Deformity Surgical Scars LOOK Long Thoracic Nerve Serratus Anterior Less common Spinal Accessory Nerve (trapezius) Dorsal Scapular Nerve (rhomboids) Scapular Dyskinesis MOST COMMON Pain may alter mechanics or vice versa Winging MOVE Range of Motion What should we measure? Flexion External rotation Internal rotation Active vs. Passive 14

Shoulder Impingement Syndrome 50 year old woman Lefthanded Has 3 month

uncomfortable Painful Arc 60-120 MOVE Flexion and External rotation

abducted to 90º Horizontally adduct to 30º External rotation Internal

15 Shoulder Impingement Syndrome 50 year old woman Lefthanded Has 3 month history of worsening pain in the Left Shoulder Doesn t remember any history of pain. Has difficulty lifting arm and reaching behind her Sleeping is uncomfortable Painful Arc MOVE Flexion and External rotation MOVE Rotator Cuff strength testing Supraspinatus Empty can Thumbs down abducted to 90º Horizontally adduct to 30º External rotation Internal rotation For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % Spec = 100 % Naredo et al. Ann Rheum Dis, 2002; 61:

Rotator Cuff strength testing Infraspinatus/teres minor - External

tendonitis, Sens = 57 % Spec = 71 % For tears, Sens = 36 % Spec = 95 %

Rotator Cuff strength testing Subscapularis Internal rotation / Lift-off

95 % Impingement Signs Impingement Signs Neer Passive full flexion

40 % NPV = 89 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 %

16 Rotator Cuff strength testing Infraspinatus/teres minor - External rotation Keep elbows at 90º Patte s test at 90º shoulder abduction For tendonitis, Sens = 57 % Spec = 71 % For tears, Sens = 36 % Spec = 95 % Naredo et al. Ann Rheum Dis, 2002; 61: Rotator Cuff strength testing Subscapularis Internal rotation / Lift-off test For lesions, Sens = 50 % Spec = 84 % For tears, Sens = 50 % Spec = 95 % Naredo et al. Ann Rheum Dis, 2002; 61: Impingement Signs Impingement Signs Neer Passive full flexion Positive is reproduction of shoulder pain Sens = 83 % Spec = 51 % PPV = 40 % NPV = 89 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: Hawkin s test Flex shoulder to 90º Flex elbow to 90º Internally rotate Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 % NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9:

Impingement Signs Stability Tests Spurling s

= 95% PPV = 58% NPV = 96% Apprehension test -

90 Externally rotate arm Sens = 69 % Spec = 50 %

J Bone Joint surg Am, 1981; 63: 863-872.

Externally rotate arm Sulcus sign (MDI) No Sens

17 Impingement Signs Stability Tests Spurling s test for cervical radiculopathy Sens = 64% Spec = 95% PPV = 58% NPV = 96% Apprehension test - caution if acute dislocation Abduct shoulder to 90 Externally rotate arm Sens = 69 % Spec = 50 % For labral tear Rowe CR, Zarins B. J Bone Joint surg Am, 1981; 63: Stability Tests Apprehension test - caution if acute dislocation Abduct shoulder to 90 Externally rotate arm Sulcus sign (MDI) No Sens / Spec Data Stability Tests Sens = 69 % Spec = 50 % For labral tear Rowe CR, Zarins B. J Bone Joint surg Am, 1981; 63:

Labral Test (O Brien Test) Step 1: Palm Down Step 2: Palm Up Labral Test (O Brien Test) Step 1: Palm Down Step 2: Palm Up

100 % Spec = 97 % 100 % Spec = 97 % Rotator Cuff Tear vs Impingement? Summary Difficulty lifting Pain vs weakness?

J Shoulder Elbow Surg, 2002; 11: 219-224.

18 Labral Test (O Brien Test) Step 1: Palm Down Step 2: Palm Up Labral Test (O Brien Test) Step 1: Palm Down Step 2: Palm Up For labral tear, + pain deep in shoulder Sens = % Spec = % For AC joint pathology, + pain over AC joint Sens = 100 % Spec = 97 % For labral tear, + pain deep in shoulder Sens = % Spec = % For AC joint pathology, + pain over AC joint Sens = 100 % Spec = 97 % Rotator Cuff Tear vs Impingement? Summary Difficulty lifting Pain vs weakness? Drop arm sign Fail conservative Tx Tears uncommon < 40 y.o. Sens = 10 % PPV = 100 % Bryant et al. J Shoulder Elbow Surg, 2002; 11: Think History first to make the diagnosis Reproduce the mechanism of injury during the exam Master Look Feel Move 18

19 12 th UCSF Primary Care Sports Medicine Conference San Francisco, Dec 1-3, 2017 Hotel Intercontinental 19

Overview. MSK talks. Primary Care Sports Medicine. Examining the History and Examination for Common MSK Problems

Overview. MSK talks. Primary Care Sports Medicine. Examining the History and Examination for Common MSK Problems Primary Care Sports Medicine Examining the History and Examination for Common MSK Problems A n t h o n y L u k e MD, MPH, CAQ (Sport Med) Associate Professor, Director Primary Care Sports Medicine Primary