PRIMARY CARE EXAMINATION OF KEY JOINTS Thomas M. Howard, MD, FACSM FFPC Sports Medicine General exam principles: Expose entire joint and opposite limb for comparison Have a Differential Diagnosis Exam format per Stanley Hoppenfeld: Observation ROM Palpation-bony and soft tissue Strength and neuro testing Special tests Exam of related areas
Shoulder Exam Standing (or sitting) Observation-atrophy; shoulder height; scapular position and motion w ROM ROM-Abd 180; FF 180; arm @ side IR 80, ER 70; arm abducted IR 70, ER 80-90 (IR + ER ~ 180); Apley Scratch Palpation-anterior joint, AC, Clavicle, Biceps, scapula and periscapular Strength-ER, Supraspinatus (empty n), Subscap (Subscap Lift Off, Bear Hug, Tummy press) Special Tests-Obrien, Speed s, Yergason s, Cross-Chest Test, Impingement (Hawkins, Neer), Shoulder slide, Sulcus, Roo Test, Adson s Exam of Related Areas-Neck ROM, Spurling s, UE Neuro ROM Special Tests AAT, Relocation, Sulcus, slide, Crank DDx <25 25-55 >55 Fractures- All the same Fractures Clavicle Humerus Scapula AC Separation Dislocation Ant Subluxation Labral injury Overuse Overuse Overuse Tendonitis Tendinitis Tendinosis Instability Impingement RC Tear RC Tendinosis RC Tears Other Referred Adhesive psulitis Other Referred
Knee exam Walking Observation-gait, stride length, foot pronation Sitting Observation-swelling, ecchymosis or deformity, patellar tracking with active extension Palpation-joint line (med and lat); pes anserine bursa; patellar tendon; tibial tubercle and inferior patellar pole; Quad tendon and med and lat reinaculae; palpation of patella with active extension Strength-hip flexor Special test-modified Lachman Observation-swelling, ecchymosis, deformity, atrophy ROM-passive exam (0-135) Palpation-effusion; plica?; reconfirm JLT and patellar tendon tenderness Special tests- Patellar-patellar grind, tether, apprehension Meniscus-Steinmann, McMurray Ligament-Lachman; anterior drawer; posterior drawer; pivot shift; MCL and LCL Exam of Related Areas-leg lengths; Q angle; Quad girth; Popliteal Angle Standing Observation-valgus or varus deformity Special Tests-Thessally, Trendelenberg Functional tests-single leg hop; single leg forward hop; squat and duck walk DDx Medial MCL Medial meniscal tear Med Compartment OCD Pes Anserine Bursitis Stress Fx-Tibial or Femoral Ant PFS Patellar Tendon (rupture, tendinosis, tendonitis) Quad Tendon (rupture, tendinosis, tendonitis)
Plica Osgood Schlatter Pre-Patellar Bursitis Patellar Fx Referred from hip Lateral LCL (usually not in isolation usually w ACL) Lat meniscal tear Discoid meniscus ITB Tibial Plateau Fx Baker s Cyst HS strain Popliteus Referred neurogenic pain Acute hemarthrosis-acl, Patellar Dislocation, Fx, Peripheral Meniscal Tear All knee pain in <25 age group = PFS until proven otherwise An effusions in a child is NOT NORMAL Historical Clues: PFS-Theater Sign, pain w stairs, grinding, grabbing front of knee Twisting, valgus injury-med meniscus, ACL, MCL, Patellar Dislocation Pivoting-type giving way= ACL; In-Line giving way=anterior knee pain Locking-meniscal tear or loose body
Ankle Exam Walking Observation-gait; weight bearing?; pronation? Sitting Observation-swelling or ecchymosis ROM-DF 20; PF 50; inversion 5; eversion 5 Palpation-prox fibula; lat malleolus; med malleolus; Anterior joint (med and lat); anterior Tib-Fib joint; peroneal tendons; posterior tibial tendon; Achilles; 5 th Met; Navicular; posterior heel Special Tests-Tib-Fib squeeze; Anterior Drawer; Talar Tilt; External Rotation or Cotton Test; Tinel s over the Tarsal Tunnel Neuro testing-1 st dorsal web space sensation; strength-df, PF, Inversion, Eversion Standing Observation-ability to weight bear; foot pronation; Too Many Toes? ; heel inversion with rise on toe Neuro Testing-single leg balance Special tests-modified Anterior Drawer Prone Special Tests-Thompson s DDx: Med Tibial Tendon, Deltoid Lig Sprain, Tibial Fx, Navicular, Tarsal Tunnel Anterior Tibialis Anterior Tendonitis,, OCD, High Ankle Sprain, Instability Lateral ATFL or CFL Sprain, Peroneal Tendon (tear or dislocation), Cuboid Fx, 5 th Met, Fib Fx Os Trigonum, Achilles (tear, tendinosis), Retrocalcaneal Bursitis, lcaneal Fx Rule of 85 s-85% are sprains; 85% are lateral; 85% involve the ATFL