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 quadriceps muscles extend the knee The quadriceps muscles merge to form the quadriceps tendon patellar tendon http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/thigh+and +Leg+ +Lecture+Notes The hamstrings flex the knee Pes anserine bursa www.hep2go.com http://meded.ucsd.edu/clinicalmed/joints.htm
There are 4 main ligaments in the knee Meniscus Knee exam Musculoskeletal work up History Inspection Palpation Range of motion Other Tests
Common Causes of Knee Pain by Location of Symptoms Diagnosis of knee osteoarthritis 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. Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039 49. Palpation of joint line seated or supine Palpation of patella - supine http://www.rheumors.com/kneeexam/palpation.html Ballottement
Palpation of patellar facet Knee range of motion ROM: normal 0 135 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 75 100% Specificity 95 100% PCL: Posterior Drawer Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008.
MCL and LCL MCL and LCL grading Grade Injury Translation compared to unaffected side I Strain Minimal laxity, firm endpoint II Partial tear Some laxity, firm endpoint III Complete tear Obvious laxity, no endpoint Patient response Pain Pain, may feel loose Minimal pain, may feel very loose 4 tests for meniscus tear Meniscus: McMurray 1. Isolated joint line tenderness 2. McMurray 3. Thessaly 4. Squat These tests not needed in patients with knee OA. Do these tests in patients < 50 with isolated joint line tenderness. Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008.
Meniscus: Thessaly Meniscus: Squat Standing: inspection Varus or valgus Sitting: palpation Joint line Femoral condyles Tibial plateau Fibular head Knee exam practice 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 Shoulder anatomy
Underlying Anatomy Bones Acromion The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa Humerus Scapula o Glenoid o Acromion o Coracoid o Scapular body Clavicle Sternum Clavicle Glenohumeral Joint Lesser Tuberosity Greater Tuberosity The Rotator Cuff Muscles (SITS) Acromion Spine of scapula is at the level of T3 The tendons of the rotator cuff muscles reinforce the capsule of the glenohumeral joint. Bottom of scapula is at level of T7 Subscapularis (Internal Rotation) Lesser Tuberosity Anterior View
Greater Tubersosity Teres Minor (External rotation) Supraspinatus (Abduction) Posterior View Infraspinatus (External rotation)) The Biceps Muscle #1 Supination of the elbow (screwing, twisting) #2 Flexion of the elbow Long head Short head 3 attachments: Radial tuberosity (distal) Glenoid (long head) Coracoid (short head) Shoulder exam Shoulder examination Key Components of the Shoulder Exam: Neck Shoulder Inspection Palpation Range of Motion: abduction, flexion, ER, IR Strength Neurovascular Special Tests: Hawkins impingement sign Neers impingement sign Painful arc (rotator cuff dz) Jobe s, aka Empty can (supraspinatus) Drop arm test (rotator cuff dz) External rotation lag test (rotator cuff tear) Internal rotation lag test (rotator cuff tear) Speeds (biceps) Yergason s (biceps) O briens (SLAP tear) AC crossover (AC joint OA or sprain)
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 Inspection Patient in gown Palpation ROM Strength Supra Infra and teres minor Subscapularis Other tests Shoulder examination Inspection Presence of infraspinatus atrophy increases likelihood of rotator cuff disease Positive LR 2.0 Negative LR 0.61 Litaker D et al, J Am Geriatr Soc, 2000.
Shoulder examination Range of motion Inspection Palpation ROM Strength Supraspinatus Infraspinatus & Teres minor Subscapularis Other tests Abduction Flexion Range of motion Supine shoulder PROM Internal rotation External rotation
Passive range of motion If limited AROM in any direction Follow up by testing passive motion in that direction If limited active and passive ROM think Frozen shoulder Glenohumeral joint arthritis Shoulder exam practice Neck: palpation, ROM and Spurling s maneuver Inspection Palpation AROM Abduction Flexion External rotation (ER) Internal rotation (IR) PROM 1 Shoulder: diagnosis driven exam Other tests Normal Weak = Rotator cuff tear Limited by pain = Other rotator cuff dz Labral tear Biceps tendinitis AC joint OA Frozen shoulder Active ROM Normal Normal Decreased Passive ROM Decreased Xray Abnormal GH joint OA Rotator cuff disease (RCD) Bursitis or impingement Tendinitis/tendinopathy Partial tear Full thickness tear Biceps tendinitis/tendinopathy Labral tear AC joint osteoarthritis
Rotator cuff disease exam Pain test: Impingement signs Pain provocation tests Pain and strength tests Often the pain radiates to lateral shoulder/proximal arm ( deltoid ) Hawkin s Neer s Pain test: Painful arc If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD. Exam practice: pain provocation tests in RCD Hawkins impingement sign Neers impingement sign Painful arc (rotator cuff dz) 2 JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.
Pain & Strength test: Supraspinatus = abduction Pain/strength test: Drop arm test Supraspinatus 71% sensitivity 41% specificity for rotator cuff disease. (+) LR 1.3 Empty can (aka Jobe s) Positive LR 3.3, negative LR 0.82 for rotator cuff disease. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Physical exam maneuvers that increase likelihood of full thickness rotator cuff tear 1. External rotation lag test 2. Internal rotation lag test Strength test: External rotation lag test Positive LR 7.2, Negative LR 0.57 for full thickness rotator cuff tear https://www.healthbase.com/hb/images/cm/p rocedures/orthopedics/rotator_cuff_tear.jpg JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.
Pain & Strength test: Subscapularis = internal rotation lag test Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Exam practice: Rotator cuff strength and tear Jobe s, aka Empty can (rotator cuff disease) Drop arm (rotator cuff disease) External rotation lag test (rotator cuff tear) Internal rotation lag test aka Lift off test (rotator cuff tear) 3 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 Also tests for biceps strength Sens = 41%, Spec = 79%
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 Exam practice: biceps tendinitis, labral tear, AC OA Speeds (biceps) Yergason s (biceps) O briens (SLAP tear) AC crossover (AC joint OA or sprain) 4 Key Components of the Shoulder Exam: Neck Shoulder Inspection Palpation Range of Motion: abduction, flexion, ER, IR Strength Neurovascular Shoulder examination Special Tests: Hawkins impingement sign Neers impingement sign Painful arc (rotator cuff dz) Jobe s, aka Empty can (supraspinatus) Drop arm test (rotator cuff dz) External rotation lag test (rotator cuff tear) Internal rotation lag test (rotator cuff tear) Speeds (biceps) Yergason s (biceps) O briens (SLAP tear) AC crossover (AC joint OA or sprain)
Thank you Questions? Carlin.Senter@ucsf.edu