Outline. Knee Anatomy. Physical Exam Skills and Office Procedures in Orthopaedics. The quadriceps muscles extend the knee 7/23/2013

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and injection Shoulder exam Subacromial bursa

1 Physical Exam Skills and Office Procedures in Orthopaedics Outline Knee exam Knee aspiration and injection Shoulder exam Subacromial bursa injection UCSF Essentials of Primary Care August 14, 2012 Carlin Senter, M.D. Knee Anatomy The quadriceps muscles extend the knee +Leg+ +Lecture+Notes 1

2 The quadriceps muscles merge to form the quadriceps tendon patellar tendon The hamstrings flex the knee Pes anserine bursa There are 4 main ligaments in the knee 2

$meniscus tear or OA - IT band syndrome - LCL sprain (rare) - Fibular head: fracture (rare) Medial - Medial joint-line: meniscus tear or$

3 Meniscus Knee exam Musculoskeletal work up Common Causes of Knee Pain by Location of Symptoms History Inspection Palpation Range of motion Other Tests 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. 3

4 Inspection Palpation of joint line seated or supine 10/09/06/valgus knee and bunion/ inicalmed/joints.htm Palpation of patella - supine Palpation of patellar facet Ballottement 4

Knee range of motion ROM: normal 0 135 Determine if

arthroscopy Other Tests: Lachman to evaluate ACL

use provided by Dr. Charles Goldberg, UCSD Magee, DJ.

5 Knee range of motion ROM: normal 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 ACL Sensitivity % Specificity % Permission for use provided by Dr. Charles Goldberg, UCSD Magee, DJ. Orthopaedic Physical Assessment, 5 th ed PCL: Posterior Drawer MCL and LCL 5

Meniscus: McMurray Meniscus: Thessaly Sensitivity

Orthopaedic Physical Assessment, 5 th ed. 2008.

Varus or valgus Sitting: palpation Joint line Femoral

facets Patellar grind ROM Special tests Lachman

6 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5 th ed 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 6

06 No evidence for long term pain relief Clinical effect independent of degree of inflammation present Don t need to restrict injection just to those with effusion Frequency: general practice once

7 Knee aspiration and injection Intra articular corticosteroid injections: do they work for knee OA? Good short term pain relief Effect size 0.72 at 2 and 3 weeks No significant effect on function Effect size 0.06 No evidence for long term pain relief Clinical effect independent of degree of inflammation present Don t need to restrict injection just to those with effusion Frequency: general practice once every 3 months max Concern for cartilage toxicity with more than 4/year AAOS: recommends for short term pain relief (level II) Zhang W et al. OARSI recommendations for the management of hip and knee osteoarthritis: Osteoarthritis Cartilage Apr;18(4): Superolateral approach Patient supine Extend knee Bump under knee so flexed degrees Superior border patella Lateral border patella 1cm below Mark with syringe cover or tip of pen Injection set up bucket Betadine Ethyl chloride Alcohol swabs 4x4 guaze Bandaids 7

Injection prep Needles, syringes, meds Corticosteroids Why use local

Dilute the steroid Decrease likelihood of steroid atrophy Decrease

relief Diagnostic and therapeutic (subacromial more than knee)

8 Injection prep Needles, syringes, meds Corticosteroids Why use local anesthetic with steroid injection? Dilute the steroid Decrease likelihood of steroid atrophy Decrease irritant nature of steroid crystals causing post injection flare Pain relief Diagnostic and therapeutic (subacromial more than knee) Floculation: combining steroid and local anesthetic can precipitate crystals. Carefully inspect for precipitate before injection. 8

9 Aspiration Why aspirate the effusion before injection? Clinically Decreased pain and stiffness because effusion gone More effect of steroid because not diluted by effusion Inspect fluid for inflammation/infection, send to lab if question Confirms that injxn was intra articular Significantly greater improvement in VAS for patients who had joint aspirated at time of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.) Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.) Post injection patient instructions Rest: no definitive evidence based recommendation Recommendations in literature vary No restrictions Bed rest x 24 hours Light activity x 7 days, no weight bearing exercise Avoid swimming, hot tub, bath x 24 hours Let injection site heal Contraindications to steroid injection Joint infection Fracture Prosthetic joint Hemarthrosis (theoretically higher risk of infection) Soft tissue infection overlying joint 9

Relative contraindications to steroid injection Corticosteroid injection within past 4 months Coagulopathy (ok if on warfarin but check recent INR, make sure not >> 3) Poorly controlled diabetes

10 Relative contraindications to steroid injection Corticosteroid injection within past 4 months Coagulopathy (ok if on warfarin but check recent INR, make sure not >> 3) Poorly controlled diabetes Risks of steroid injection in the knee Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days Suppression of hypothalamic pituitary adrenal axis, mild Lasts 1 3 days post injection Facial flushing: 10% with Kenalog hours post injection Skin or fat atrophy Post injection steroid flare: 1 10% Synovitis in response to injected crystals Within hours 48 hours post injection More common in soft tissue injections (20% of trigger points) than intraarticular injections Septic arthritis: 1/3000 1/50, days after injection Possible risk of chondrocyte toxicity with repeated injections Habib GS. Clin Rheumatol, UpToDate, Joint aspiration or injection in adults, My current knee injection steps Knee injection 1. Patient supine with bump under knee 2. Mark injection site (superior lateral) 3. Betadine x 3 4. Alcohol x 1 5. Ethyl chloride for skin anesthesia 6. Alcohol again 7. 22g needle attached to 10cc syringe containing 5cc of 1% lidocaine without epi 8. Slowly advance and inject lidocaine, 1mm at a time 9. Feel resistance give when in joint 10. Aspirate, make sure fluid straw colored and clear 11. Keep needle in place, switch syringe 12. Inject 1cc of 40mg kenalog 10

Shoulder anatomy Underlying Anatomy Bones Acromion Humerus

Sternum Clavicle Glenohumeral Joint Lesser Tuberosity Greater

attaches to the glenoid rim & deepens the glenoid fossa Acromion

11 Shoulder anatomy Underlying Anatomy Bones Acromion Humerus Scapula o Glenoid o Acromion o Coracoid o Scapular body Clavicle Sternum Clavicle Glenohumeral Joint Lesser Tuberosity Greater Tuberosity The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa Acromion Spine of scapula is at the level of T3 Bottom of scapula is at level of T7 11

The Rotator Cuff Muscles (SITS) The tendons of the rotator cuff

Greater Tubersosity Supraspinatus (Abduction) Posterior View

Teres Minor (External rotation) Infraspinatus (External

(screwing, twisting) #2 Flexion of the elbow Shoulder exam Long

12 The Rotator Cuff Muscles (SITS) The tendons of the rotator cuff muscles reinforce the capsule of the glenohumeral joint. Greater Tubersosity Supraspinatus (Abduction) Posterior View Lesser Tuberosity Subscapularis (Internal Rotation) Anterior View Teres Minor (External rotation) Infraspinatus (External rotation)) The Biceps Muscle #1 Supination of the elbow (screwing, twisting) #2 Flexion of the elbow Shoulder exam Long head Short head 3 attachments: Radial tuberosity (distal) Glenoid (long head) Coracoid (short head) 12

Inspection Palpate CS FF and extension Spurlings Neck examination Neck

cervical spine Reproduction of patient s shoulder/arm pain indicates

Shoulder examination Shoulder examination Inspection Patient in gown

tests http://meded.ucsd.edu/clinicalmed/joints 2.

Charles Goldberg, UCSD SOM Inspection Palpation ROM Strength

13 Inspection Palpate CS FF and extension Spurlings Neck examination 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 Cervical Spine Spurling s Maneuver Shoulder examination Shoulder examination Inspection Patient in gown Palpation ROM Strength Supra Infra and teres minor Subscapularis Other tests 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM Inspection Palpation ROM Strength Supraspinatus Infraspinatus & Teres minor Subscapularis Other tests almed/joints2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM 13

14 Range of motion Range of motion Internal rotation Abduction Flexion External rotation Supine shoulder PROM Other tests Rotator cuff strength Impingement tests Biceps Labrum AC joint 14

15 Supraspinatus = abduction Infraspinatus and teres minor = external rotation Supraspinatus Empty can Infraspinatus Teres minor Photos from Dr. Christina Allen Photos from Dr. Christina Allen Subscapularis = internal rotation Subscapularis = internal rotation Lift Off Subscapularis Belly press Subscapularis Photos from Dr. Christina Allen Photos from Dr. Christina Allen 15

Impingement syndrome Impingement signs Inflammation of the subacromial space The area

Supraspinatus Subacromial/subdeltoid bursa Subacromial bursa Supraspinatus Hawkin s

Christina Allen Neer s Biceps Tests: Speeds Tests for biceps pathology (tendinitis,

flexion) +Test is pain at proximal biceps tendon Sens = 54%, Spec = 81% Biceps Tests:

16 Impingement syndrome Impingement signs Inflammation of the subacromial space The area under the acromion and above the glenohumeral joint Structures in this space Supraspinatus Subacromial/subdeltoid bursa Subacromial bursa Supraspinatus Hawkin s Photos from Dr. Christina Allen Neer s 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 tendon Sens = 41%, Spec = 79% 16

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

patient or physician +Test is pain at AC joint Testing the AC Joint: AC Crossover Key Components of the Shoulder Exam: Shoulder Exam Hands On Inspection

Empty can (supraspinatus) Lift off test (subscapularis) Resisted external rotation (infraspinatus) Hawkins (impingement sign) Neers (impingement sign) Speeds

17 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% O Brien s Test To r/o Labral Tear Tests for AC joint osteoarthritis or sprain Can be done passively by patient or physician +Test is pain at AC joint Testing the AC Joint: AC Crossover Key Components of the Shoulder Exam: Shoulder Exam Hands On Inspection Palpation Range of Motion: abduction, flexion, ER, IR Strength Neurovascular Special tests Special Tests: Spurling s (cervical spine radiculopathy) Job s, aka Empty can (supraspinatus) Lift off test (subscapularis) Resisted external rotation (infraspinatus) Hawkins (impingement sign) Neers (impingement sign) Speeds (biceps) Yergason s (biceps) O briens (SLAP tear) AC crossover (AC joint OA or sprain) Subacromial injection for impingement syndrome 17

Impingement syndrome Inflammation of the subacromial space The area under the acromion and above the glenohumeral joint Structures in this

Lateral Slide courtesy of Anthony Luke, M.D.

needle at Posterior soft spot Aim parallel to angle of lateral acromion to reach subacromial bursa Direct needle towards opposite nipple

18 Impingement syndrome Inflammation of the subacromial space The area under the acromion and above the glenohumeral joint Structures in this space Supraspinatus Subacromial/subdeltoid bursa Subacromial bursa Supraspinatus Approach 1. Posterior 2. Lateral Slide courtesy of Anthony Luke, M.D. Subacromial Injection Subacromial Injection Posterior approach Landmarks Posterior and lateral borders of acromion Coracoid Technique Insert needle at Posterior soft spot Aim parallel to angle of lateral acromion to reach subacromial bursa Direct needle towards opposite nipple Lateral approach Landmarks Lateral border of the acromion Technique Inject 3 mm below lateral border of the acromion Angle needle parallel to plane of the acromion Slide courtesy of Anthony Luke, M.D. Slide courtesy of Anthony Luke, M.D. 18

Subacromial Injection Subacromial injection

19 Subacromial Injection Subacromial injection palpation 5 8 ml combination of local anesthetic solutions 1 2 ml steroid solution My preferred solution: 5mL 1% lidocaine with 1 ml 40 mg/ml triamcinolone Subacromial injection Thank you Questions? Carlin.Senter@ucsf.edu 19

Mastering the Musculoskeletal Exam UCSF Essentials of Women s Health July 7, 2016 Carlin Senter, M.D. Henry Crevensten, M.D.

Mastering the Musculoskeletal Exam UCSF Essentials of Women s Health July 7, 2016 Carlin Senter, M.D. Henry Crevensten, M.D. I have nothing to disclose Outline Knee exam Shoulder exam Knee Anatomy The