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Copyright 2002 CareGroup
Occupational Health Network
Provocative Testing & Diagnostics of Upper & Lower
Extremity Conditions
Tom Winters, MD, FACOEM, FACPM
Chief Medical Officer
CareGroup Occupational Health Network
Walter Panis, MD
Medical Director
CareGroup Occupational Health Network
June 6, 2002
The Knee
• Approx. 10.8 million knee injuries per year in general population
• Why so many injuries– Largest joint in body
– Dynamic nature of joint increases vulnerability
– Very little bony stability- relies on normal ligaments, cartilage and tendons
Ref: AAOS Research Dept., Pt. Visits for selected conditions, 1998
Anatomy of the Knee
• Bones:– Femur– Tibia– Patella
• Cartilage (shock absorbers)– Lateral Meniscus– Medial Meniscus– Articular cartilage is
nerveless
Anatomy of the Knee
• Ligaments– 4 major ligaments
(attach bone to bone)• Anterior Cruciate
• Posterior Cruciate
• Medial Collateral
• Lateral Collateral
Anatomy of the Knee
• Patellar and Extensor tendons (attach Quadriceps to bone)– Major tendons
• Synovium– Inner joint lining
• Synovial fluid– Joint lubrication
Types of Knee Injuries
• ACL tear• Bursitis (“Housemaids
knee”)• Collateral ligament
tear• Posterior ligament
tear• Meniscal tear
• Fracture of tibia• Fracture of patella• Sprain/strain• Patellar/quadriceps
tendinitis• Patellofemoral pain• Extensor mechanism
rupture
Types of Knee Injuries
• Ligament Injuries– ACL: changing direction
quickly, twisting, pivoting, deceleration activities
– PCL: blow to front of knee (“dashboard injury”), hyperextension / hyperflexion
– MCL: contact with outside of knee, valgus force (common)
– LCL: knee forced laterally, varus force (less common)
Types of Knee Injuries (cont.)
• Meniscal Tears– Medial/Lateral
Meniscal Tear:• Twisting,cutting,
pivoting, rapid deceleration types of motions
• Movement around a fixed lower leg (stationary) or planted foot
Examination of the Knee• Inspection (always examine
uninjured knee 1st!)– Note onset- acute/gradual– Type/quality of pain– Posture– Bony deformities– Muscle wasting
• Quad wasting esp. in VM O seen with knee injury
– Soft tissue swelling• Effusion of suprapatellar pouch,
pre and infrapatellar bursae, palpable joint line swelling
– Masses/lumps– Old scars– Pulses
Examination of the Knee (cont.)
• Palpation– Check bilaterally for temperature
differences, inflammation
– Palpate medial and lateral collateral compartments
– Bursae
– Medial/lateral meniscus
– Medial/lateral ligament• Medial more common
• “Bucket-handle” tear
– Popliteal fossa
Examination of the Knee (cont.)
• Palpation (cont.)– Bony landmarks
• Medial and lateral joint lines
• Patello-femoral joint
• Tibial tuberosity
• Femoral condyles
– Reflexes
– Always check joint above and below (hip and ankle); hip pain may be referred to knee!
Examination of the Knee (cont.)
• Range of motion– Flexion = 130+
degrees
– Extension = 0 - (-10) degrees
Special Knee Tests
• Tests for ACL laxity– Anterior drawer sign
– Lachman’s test
– Pivot shift
Anterior Draw Test
Lachman’s TestRef: Snider, R. The Essentials of Musculoskeletal Care. AAOS: 1997
Special Knee Tests (cont.)
• PCL stress tests– Posterior sag sign
– Reverse Lachman’s
– Posterior draw sign
– Reverse pivot test
http://www.wokc2.com/topic3.htm
Posterior sag sign
Special Knee Tests (cont.)
• McMurray’s/ Apley’s grind test (meniscus)
• Apprehension test (patella)
• Crepitus sub-patella
• Pathological “locking/giving out”– Due to intra-articular fragment
of bone or cartilage wedging between femoral & tibial condyles
– Joint unable to fully extend (fixed flexion deformity)
McMurray’s Test
Ref: Hoppenfeld,S. Physical Examination of the Spine & Extremities. Prentice-Hall: 1976.
Grading Ligament Injuries• Grade I (sprain):
– Micro-tearing or stretching– Joint is stable
• Grade II (sprain):– Partial disruption of ligament– Painful to stress joint– Joint laxity with endpoint– Mild effusion
• Grade III (tear):– Complete tear– Joint laxity without endpoint effusion
Diagnostic Procedures
• X-ray– Indications
• MRI– Best to view:
• Meniscus, ligaments, soft tissue
– Indications
• CAT Scan– Best to view:
• Bone
– Indications
Diagnostic Procedures
• Arthrogram (infrequently performed)
• Arthroscopy (preferred method)
Treatment of Knee Injuries
• Rest• Ice• Compression• Elevation• Anti-inflammatories
– NSAIDs
– COX-2
Types of Knee Braces• Types of bracing:
– Prophylactic– Functional– Rehabilitative/knee
immobilizer– Patellorfemoral
• Often work better in lab than in real life use
• Functional and Rehabilitative seem to be of most use
• Stretching, strengthening,and technique improvement more important in long run
Anatomy of the Foot and Ankle• Bones
– “True ankle joint”• Tibia• Fibula• Talus
Second part of ankle• Subtalar joint• Calcaneus (heal)
– Foot• Tarsals• Metatarsals• Phalanges
A.
A.
Ref: http://www.soarmedical.com/medical-library/foot&ankle/
Anatomy of the Foot and Ankle (cont.)
• Cartilage & ligaments– Articular cartilage (1)
– Anterior tibiofibular (2)• Connects tibia to fibula
• Most commonly injured
– Collateral lateral ligaments (3)• Attaches fibula to calcaneus-
lateral stability
– Deltoid ligaments (4)• Connect tibia to talus and
calcaneus- medial stability
Ref: http://www.scoi.com/anklanat.htm
Anatomy of the Foot and Ankle (cont.)
• Tendons– Achilles tendon
– Anterior tibial tendon
– Posterior tibial tendon
Examination of the Ankle and Foot
• Inspection– Ecchymosis, bony abnormalities, soft tissue swelling, effusion– Note type of footwear- note wear pattern on soles– Gait
• Palpation– Tenderness- certain areas of foot normally tender i.e.sinus
tarsi, distal aspect of ball between metatarsals– Neurovascular status- Pulses, sensation– Crepitation– Tinel’s sign (+ peroneal nerve injury)
• Range of motion
Special Tests of the Ankle and Foot
• Eversion stress (Medial stress test)• Drawer test• Anterior drawer test (tests stability-ATF ligament)• Lateral stress• External rotation test (Kleiger test)• Squeeze test (testing for fx of
tibia or fibula)• Heel tap test
Types of Ankle and Foot Injuries
• Plantar fasciitis• Tarsal tunnel
syndrome (ladders)• Insertional Achilles
tendinitis• Stress fracture of
calcaneus
• March fracture (stress fx)
• Sesamoiditis• Fracture of the
sesamoid
Sprain versus Strain
• Sprain: twisting of joint that stretches or tears ligaments, no dislocation of bones, may damage nearby blood vessels, muscles, tendons, swelling and hemorrhage
• Strain: less serious injury, overstretched tendon or partially torn muscle
Types of Ankle Injuries:Sprains
• 1st degree: no (mild) edema, point tenderness, ligament stretching, no rupture (maybe crutches/cane)
• 2nd degree: partial ligament rupture, edema, point tenderness, difficulty/inability to weight bear on ankle (crutches,splint)
• 3rd degree: complete disruption one or more ligaments/other structures, edema, ecchymosis, general tenderness, inability to bear weight (crutches,splint, cast, surgery)
Ankle Sprains• Forced inversion strain
– Stretch, tear or rupture of lateral collateral ligament complex (possibly anterior talo-fibular lig.)
• Forced eversion strain– Stretch, tear or rupture of
medial collateral ligament
• Lateral ankle compartment more commonly injured than medial
Foot and Ankle Fractures
• Types– Jones (fx of proximal metaphysis of 5th
metatarsal)
• Diagnosis– Routine use of x-rays to rule out
sprain vs. fx “to do or not to do”- clinical indications
– Ottawa rules for foot and ankle radiographs (see web site) http://www.aafp.
org/afp/980201ap/wexler.html
• Treatment– ORIF– Casting
Foot and Ankle Fractures
Traumatic Injury
• Direct trauma = external force strikes the foot
• Indirect trauma = force transmitted to stationary foot so that weight of body becomes a deforming force by torque, rotation or, compression
Ref: http://www.aafp.org/afp/980700ap/burrough.html
• Why are ankle injuries so painful?– Rich nerve supply
(pain and proprioception is enhanced)
– All ligaments have poor blood supply: slow to heal, heals with scar tissue, retains stretched condition
Pain
Non-Surgical Treatment of Ankle Injuries
• Rest
• Ice
• Compression
• Elevation
Types of Ankle Support
• Non-rigid (1st degree sprains):– Elastic wrap/neoprene
• Not OSHA recordable• Purpose: compression, non-
supportive
• Rigid: (1st, 2nd, 3rd degree sprains)– Lace-up, Aircast
• Purpose: support, proprioception
– Bracing• AFO (ankle foot orthosis)• Walking boot• Cast shoe• Cast
Physical Therapy for Knee and Ankle Injuries
• Does every lower extremity injury require physical therapy?– Benefits
– How soon after injury should it be ordered?
• Home exercises versus clinic therapy program– Nature of injury
– Patient compliance issues
Goals of Rehabilitation
• Restoration of comfort– Decrease edema
• R.I.C.E.
– Address pain• NSAIDs• COX-2 agents
• Refer complications early• Maintain Mobility
– Active ROM & strengthening
• Restore proprioception– Wobble board, mini-
trampoline
• Work-hardening program or job specific exercise programs
• Prevent future re-injury– Education
• Understand injury, treatment, rehab and prevention strategies
Upper Extremity Evaluation
• History• Exam• Diagnostic studies• Key is putting all
three together to make a “total” picture
Low Back Pain
• Most commonly seen musculoskeletal injury
• In normal population 80% of us will have an LBP episode in their lifetime
• 3-4% per yr. Will be temporarily disabled
• 1% of working population will be permanently disabled
Ref: www.emedicine.com/neuro/topic516.htm
Myths of Low Back Pain
• True or false:– All people with LPB need an x-ray– Rest is good for pain– MRI or CT must be done to provide definitive
diagnosis– Vast majority of patients improve in 2-6 weeks
with or without treatment (approx. 90%)
Anatomy of the Lumbar Spine
• No lateral support in lumbar spine (> mobility in sagittal and coronal planes)
• Bony vertebrae– Transverse and spinous
processes
• Intervertebral disc– Outer annulus fibrosis
– Inner nucleus pulposus
Anatomy of the Lumbar Spine
• Anatomical relationship between L4, L5 and S1
Anatomy of the Lumbar Spine
• Specific nerve roots have specific functions and will elicit specific symptoms
Diagnosing Low Back Pain: Sprain/Strain Injury
• Vast majority of LBP is a sprain/strain injury– Ligamentous– Tendonitis
• LBP most often over R lumbar sacral area– Tends to be localized– Referred pain not
typically seen– Described as “aching”
Diagnosing Low Back Pain: Nerve Root Compression
• Back pain due to nerve root compression/radiculopathy less common– “Sciatica” is not a good term
• Sciatic nerve= combination of tibial and peroneal nerve- forms well outside spinal canal where most back problems occur
Diagnosing Low Back Pain: Nerve Root Compression
• Impingement compression pathology of spinal nerve root– Initial complaint may be “electric
shock down leg”• Mechanism= ICP due to
intrathoracic pressure venous outflow from brain ICP pressure on nerve from disc causing burning/shooting pain
– Parethesias• Numbness/tingling
– Bowel/bladder involvement• Cauda Equina Syndrome• Medical/surgical emergency
Diagnostic Studies for Low Back Pain
• X-rays– ? value
• MRI and CT scans– Asymptomatic disc
herniations are commonly found on What is diagnostic value of this?
– When should MRI or CT be done?
Two Common Presentations of Low Back Pain
• History:– 38 year old male experienced the following
after lifting a 100 pound box from the floor to a shelf at work
– 1) Localized back pain» OR
– 2) Very specific burning pain radiating to leg
Complaint #1
• Physical exam findings– Non-specific
– Reflexes normal
– ROM, gait, posture
– Palpation of spine
– Response to light touch
– Provocative testing done• Straight leg raise
• Heel to toe walk, squat and rise
• Palpation of sciatic notch
Complaint #1
• Diagnostic testing – Not usually indicated
unless red flags are present i.e. fever, wght. loss, hx of cancer, use of steroids etc.
• Likely diagnosis– Low back strain/sprain
Complaint #1
• Treatment– NSAIDs
– Physical therapy
– May need modified duty/work restrictions
– Importance of developing trusting relationship with patient to optimize outcome
• Lou Millender, MD– “Love ‘em back to
health!”
Complaint #2
• Physical exam– Specific– Motor weakness in
specific distribution– Abnormal reflexes– Sensory loss– Provocative testing
• ? Cauda Equina syndrome if unable to heel toe walk or squat
• + straight leg raise
Complaint #2
• Diagnostic testing– X-rays not useful
– MRI after 6 weeks of conservative treatment unless neuro symptoms
– Electrophysiology studies• What are they
• When are they done
• What will they show
• Likely diagnosis– Radiculopathy
Complaint #2
• Treatment– Most improve on own
– Pain control
– Physical therapy
– Prednisone/epidural steroids
– May need to be out of work for 1-2 days during acute symptoms
– Surgical intervention
– May require work restrictions/modified duty
Provocative Testing of the Shoulder
• Apley scratch test– Maneuver = touch
superior/inferior aspects of opposite scapula
– Positive result (< ROM) = rotator cuff problem
• Neer’s test– Maneuver = place arm in
forced flexion with arm fully pronated
– Positive result (pain) = sub-acromial impingement
Neer’s
Provocative Testing of the Shoulder
• Crossed arm test– Maneuver = raise arm
to 90 degrees then actively adduct arm- forces the acromion into the distal end of the clavicle
– Positive result (pain) = disorder of acromioclavicular joint
CROSSED ARM
Provocative Testing of the Shoulder
• Hawkin’s test– Maneuver = elevate arm forward
to 90 degrees while forcibly internally rotating shoulder
– Positive result (pain) = subacromial impingement or rotator cuff tendonitis
• Drop arm test– Maneuver = Passively abduct
shoulder, observe pt. lowering arm to waist
– Positive result (arm will drop to side) = rotator cuff tear
HAWKIN’S
Provocative Testing of the Elbow and Hand
• Phalen’s test– Maneuver = press back
of hands together with wrists fully flexed, hold 60 seconds
– Positive result (numbness/tingling) = carpal tunnel syndrome, median nerve
Provocative Testing of the Elbow and Hand
• Tinel’s sign– Maneuver = tap over the
carpal tunnel area (hand) or tap ulnar notch between olecranon process and medical epicondyle (elbow)
– Positive result (pain, tingling or electric sensation in hand) = carpal tunnel syndrome, median nerve in hand or ulnar nerve compromise in elbow
Case Studies
• MRI case study– Terminology
• T1 and T2 weighting
– What to look for in the report
• Electromyelogram case study– How they are done– What to look for in the
report
References
• http://.bledsoebrace.com/education/cp030012.htm
• http://bledsoebrace.com/products/products.htm
• http://www.fpnotebook.com/ORT55.htm
• http://orthoinfo.aaos.org
References
• Karen Muller, MPT, Journal of Orthopaedic & Sports Physical Therapy, 2000;30(3): 138-142
• The Physician and Sports Medicine: Patellofemoral pain
• mmg.Sechrest.com• www.kneeguru.co.uk• Taylor, S., P.T., “Diagnosis, Management and
Treatment of Knee Disorders: The Extensor Mechanism”, PowerPoint Presentation, New England Baptist Hospital, 2001.
