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Pearls in the Musculoskeletal Exam
Frank Caruso DMSc, PA-C, EMT-PSkin, Bones, Hearts & Private Parts
2019
Examination Key Points
• Area that needs to be examined, gown your patients - well exposed
• Understand normal functional anatomy
• Observe normal activity
• Palpation
• Range of Motion
• Strength/neuro-vascular assessment
• Special Tests
General Exam
Musculoskeletal Overview
Physical Exam PreviewWatch Your Patients Walk!!
Inspection
• Posture– Erectness
– Symmetry
– Alignment
• Skin and subcutaneous tissues– Swelling
– Redness
– Masses
Inspection
• Extremities
– Size
– Deformities
– Enlargement
– Alignment
– Contour
– Symmetry
Inspection
• Muscles
– Bilateral symmetry
– Hypertrophy
– Atrophy
– Fasciculations
– Spasms
Palpation
• Palpate bones, joints, and surrounding muscles for the following:– Heat– Tenderness– Swelling– Fluctuation– Crepitus– Resistance to pressure– Muscle tone
Muscles
• Size and strength affected by the following:– Genetics
– Exercise
– Nutrition
• Muscles move joints through range of motion (ROM).
Muscle Strength
• Compare bilateral muscles
– Strength
– Symmetry
– Equality
– Resistance
End FeelThink About It!!
• The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement
• Bone to bone: This is hard, unyielding –normal would be elbow extension.
• Soft–tissue approximation: yielding compression that stops further movement –elbow and knee flexion.
End Feel
• Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee extension and metacarpophalangeal joint extension.
Abnormal End Feel
• Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain -sudden hard – “vibrant twang”
• Capsular: Similar to tissue stretch but it does not occur where one would expect –range of motion usually reduced.
Abnormal End Feel
• Bone to bone: similar to normal bone – to bone but the restriction or sensation of restriction occurs before the normal end of range of movement
• Empty: detected when considerable pain is produced by movement - - no real mechanical resistance – acute bursitis – neoplasm.
Abnormal End Feel
• Springy block: similar to a tissue stretch –occurs where one would not expect it to occur – usually found in joints with menisci. There is a rebound effect – example: would feel a springy block end feel with a torn meniscus of a knee when it is locked or unable to go into full extension (usually no muscle spasm).
Range of Motion
• Active ROM and passive ROM for each joint and related muscle group
• Note – Pain
– Limited or spastic movement
– Joint instability
– Deformity
– Contracture
Range of Motion
• Passive ROM may exceed active ROM by 5 degrees.
• Active ROM and passive ROM should be equal in contralateral joints.
• Discrepancies may indicate muscle weakness or disorder.
• Use goniometer where there is increased or limited ROM.
Examination and Findings
Equipment
• Marking pencil
• Goniometer
• Tape measure
• Reflex hammer
• Inclinometer
• Mono-filament
Goniometry
• Is most appropriate for the measurement of medium and small appendicular joints
• The examination procedure and techniques used must be consistent
Lets Put It All Together!!
Joint by Joint
My Shoulder Hurts!!
ShoulderICD-9 ICD 10
• Shoulder pain – 719.41
• Rotator cuff sprain -840.4
• Rotator cuff tendonitis – 726.10
• Shoulder pain – M25.51
• Rotator cuff sprain -S43.4
• Rotator cuff tendonitis – M75.1
Shoulder/Scapula
34
36
Supraspinatus
37
38
Infraspinatus
39
Teres Minor
40
Subscapularis
41
Exam & Findings: Shoulders
• Inspect– Shoulder girdle, Clavicle, and Scapula for:– Size– Symmetry– Contour – Dislocation/winging of scapula
• Palpate– Sterno-clavicular joint– Acromioclavicular joint– Shoulder muscles– Biceps Groove
Exam & Findings: Shoulders
• Assess Active and Passive ROM
– Forward flexion
• The arm is kept straightened and brought upward through the frontal plane, and moved as far as the patient can go above his head. Note: for recording purposes, 0 degrees is defined as straight down at the patient's side, and 180 degrees is straight up
Exam & Findings:Shoulders
• Assess Active and Passive ROM
– External rotation (hands behind head)
– The patient is positioned sitting and the elbow is flexed 90 degrees
– While the elbow is held against the patient's side, the examiner externally rotates the arm as permitted
Exam & Findings: Shoulders
• Assess Active and Passive ROM
– Extension
Exam & Findings: Shoulders
• Assess Active and Passive ROM
– Abduction Adduction
Shoulder Assessment
• Several procedures are used to evaluate rotator cuff for impingement or tear―increased pain associated with inflammation or tear
• Neer test – Internally rotate and forward
flex arm at the shoulder: presses supraspinatus muscle against anteroinferior acromion
Shoulder Assessment
• Hawkins test – Forward
flexing shoulder to 90 degrees, flexing elbow to 90 degrees, and then internally rotating arm to its limit
Apley scratch test. The patient attempts to touch the opposite
scapula to test range of motion of the shoulder. (Left) Testing
abduction and external rotation. (Right) Testing adduction and
internal rotation.
Supraspinatus examination ("empty can" test). The patient
attempts to elevate the arms against resistance while the elbows are
extended, the arms are abducted and the thumbs are pointing
downward.
Infraspinatus/teres minor examination.
The patient attempts to externally rotate the arms against
resistance while the arms are at the sides and the elbows are
flexed to 90 degrees.
Subscapular Muscle Testing
• Push off
• Largest part of the rotator cuff
52
Test Maneuver Diagnosis suggested by positive result
Apley scratch
test
Patient touches superior and inferior aspects of opposite
scapula
Loss of range of motion: rotator cuff
problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the shoulder to 90 degrees and internal
rotation
Supraspinatus tendon impingement
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-arm
test
Forward elevation to 90 degrees and active adduction Acromioclavicular joint arthritis
Apprehension
test
Anterior pressure on the humerus with external rotation Anterior glenohumeral instability
Relocation
test
Posterior force on humerus while externally rotating the arm Anterior glenohumeral instability
Sulcus sign Pulling downward on elbow or wrist Inferior glenohumeral instability
Yergason test Elbow flexed to 90 degrees with forearm pronated Biceps tendon instability or tendonitis
Speed's
maneuver
Elbow flexed 20 to 30 degrees and forearm supinated Biceps tendon instability or tendonitis
"Clunk" sign Rotation of loaded shoulder from extension to forward flexion Labral disorder
FindingProbable diagnosis
Scapular winging, trauma, recent viral illness Serratus anterior or trapezius
dysfunction
Seizure and inability to passively or actively rotate
affected arm externally
Posterior shoulder dislocation
Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular
nerve entrapment
Pain radiating below elbow; decreased cervical range
of motion
Cervical disc disease
Shoulder pain in throwing athletes; anterior
glenohumeral joint pain and impingement
Glenohumeral joint instability
Pain or "clunking" sound with overhead motion Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
IMPINGEMENT
55
Patient Symptoms: Impingement
• I can’t sleep at night, my shoulder is killing me
• It is too painful to raise up my arm
• It feels like my bones are rubbing together
• My arm is painful and weak
• My shoulder, neck and arm are hurting me
56
Exam Summary:
• Pain with painful arc maneuver – subacromialimpingement
• Focal subacromial tenderness• Painless testing of resisted abduction
(supraspinatus), external rotation (infraspinatus), adduction ( subscapularis), and elbow flexion (Biceps)
• Normal range of motion of the glenohumeraljoint
• Preserved strength in all directions
57
ROTATOR CUFF TENDONITIS
62
Patient Symptoms: Rotator Cuff Tendonitis
• I can’t reach up my back anymore
• Whenever I move in certain directions, I get a sharp deep pain in my shoulder
• My arm feels better by hanging it over the bed
63
Exam Findings:
• Focal subacromial tenderness
• Subacromial impingement, a positive painful arc test
• Positive Flexion Abduction Resistance (FAR)
• Normal range of motion of glenohumeral joint
• Preserved rotator cuff strength – no gross weakness
64
ADHESIVE CAPSULITIS – FROZEN SHOULDER
65
Patient Symptoms: Adhesive Capsulitis
• My shoulder is stiffening up
• I can’t reach up over my head
• It’s getting harder and harder to put my coat on
• My shoulder used to be painful, pain has improved by I can’t move it now
66
Exam Summary
• Loss of external rotation with elbow at side
• Restricted abduction
• My shoulder makes this terrible clunking noise
• No radiographic evidence of glenohumeral osteoarthritis
67
ROTATOR CUFF TENDON TEAR
69
Patient Symptoms: Rotator Cuff Tear
• I have no strength in my shoulder any more
• Every time I roll my shoulder, it pops
• I can’t sleep on my back any more, there is this spot of pain over my shoulder blade
70
Exam Summary:
• Weakness in testing of rotator cuff muscles
• Rule out central lesion
• Positive drop arm test
• High riding humeral head (older patients)
71
ACROMIO-CLAVICULARSTRAIN/OSTEOARTHRITIS
78
Acromioclavicular Joint(AC)
ICD-9• AC joint pain: 719.41
• AC joint sprain: 840.0
• AC joint subluxation/dislocation: 831.04
• AC joint arthritis, unspecified: 716.91
• AC joint arthrosis, primary: 715.11
• AC joint arthrosis, posttraumatic: 716.11
• AC joint arthrosis, secondary: 715.21
ICD-10• AC joint pain: M25.51
• AC joint sprain: S43.5
• AC joint subluxation/dislocation:S43.1
• AC joint arthritis, unspecified: M13.91
• AC joint arthrosis, primary: M19.01
• AC joint arthrosis, posttraumatic: M19.11
• AC joint arthrosis, secondary: M19.21
Patient Symptoms : AC Joint
• Whenever I reach up or across my shoulder, I get a pain right here
• I fell off my mountain bike and landed right on my shoulder. Ever since then I have had achy pain
• If I reach up, I feel a grinding in my shoulder
80
Exam Summary
• AC joint enlargement/tenderness
• Pain aggravated by downward traction or forced adduction, performed passively
• AC joint widening
81
BICEPS TENDONITIS
83
Patient Symptoms: Biceps Tendonitis
• The front of my arm hurts when I use it
• I get this pain right here whenever I move my shoulder
• My shoulder has been sore for a long time. Yesterday, I tried to place my trailer on the hitch when I felt and heart this loud pop
• My shoulder used to hurt a lot everyday. Two days ago, it stopped hurting. What is this large bruise near my elbow?
85
Exam Summary
• Local tenderness in the bicipital groove
• Pain aggravated by flexion of the elbow
• A bulge in the antecubital fossa, possible rupture of the long head tendon.
86
Scapulothoracic Syndrome
ICD-9
• Bursitis of shoulder: 727.3
• Specified injury to scapula: 719.48
• Unspecified injury to scapula: 959.2
• Other specified arthropathy of scapula: 716.81
• Unspecified arthropathy of scapula: 716.91
ICD10
• Bursitis of shoulder: M75.5
• Specified injury to scapula: S49.8
• Unspecified injury to scapula: S49.9
• Other specified arthropathy of scapula: M19.81
• Unspecified arthropathy of scapula: M19.91
SUBSCAPULAR BURSITIS
89
Exam Findings
• Weakness on muscle testing
• Levator scapulae tenderness
• Rule out central lesion (cervical nerve root)
91
Patient Symptoms: Subscapular
• My shoulder blade is killing me
• My shoulder and neck is hurting me
• Sitting at a computer is very painful
92
Exam Summary
• Local tenderness under the superomedial angle of the scapula
• Full range of motion of the shoulder
• No evidence of cervical root irritation or rhomboid or trapezius muscle strain
93
GLENOHUMERAL OSTEOARTHRITIS
95
Glenohumeral Joint
ICD-9
• Shoulder pain: 719.41
• Shoulder adhesive capsulitis: 726.0
• GH joint arthritis, unspecified: 716.91
• GH joint arthrosis, post-traumatic: 715.11
• GH joint arthrosis , secondary: 715.21
ICD-10
• Shoulder pain: M25.51
• Shoulder adhesive capsulitis: M75.0
• GH joint arthritis, unspecified: M 13.91
• GH joint arthrosis, post-traumatic: M19.01
• GH joint arthroisis , secondary: M19.21
Patient Symptoms: OA
• My shoulder makes a terrible clunking noise, my shoulder is stiff
• I can’t do anything with my shoulder
• Sleeping is terrible – the slightest move wakes me up at night
97
Exam Findings
• Crepitation with circumduction or clunking sensation with range of motion
• Restricted abduction and internal rotation
• General fullness of the shoulder
98
MULTI-DIRECTIONAL INSTABILITY
100
Patient Symptoms: Multi-Directional Instability
• It feels like my shoulder is going to pop out
• Every time I try to lift something heavy, my shoulder seems to slip
• I don’t trust my shoulder anymore
101
Exam
• Downward traction on the arm causes the sulcus sign
• Increased antero-posterior mobility of the humeral head
• A positive apprehension sign when the arm is placed at 70 – 80 degrees of abduction and passively rotated externally
102
SIMON SAYS MY ELBOW HURTS
104
Elbow/Forearm
106
Exam & Findings: Elbows
• Inspect
– Contour
– Carrying angle
– Subcutaneous nodules
• Palpate elbow, olecranon bursa, and grooves on each side of olecranon for:
– Tenderness
– Swelling
– Thickening
Exam & Findings: Elbows• Assess ROM and
strength – Flexion
– Extension
STABILITY
Testing mediolateral elbow
stability
To eliminate interfering movements during
varus instability testing, the humerus is
placed in full internal rotation and the
forearm in pronation.
To eliminate interfering movements during
valgus instability testing, the humerus is
placed in full external rotation.
Valgus testing is done with the forearm
pronated, to test the medial collateral
ligament, followed by testing in supination,
to check the lateral collateral complex.
LATERAL EPICONDYLITIS
110
Lateral Epicondylitis
• CPT: 20551 Injection of tendon origin or insertion
• ICD-9: 726.32
• ICD-10: M77.1
Patient Symptoms: Lateral Epicondylitis
• I can’t even pick up a coffee cup without severe pain
• After a couple of hours of using screw driver, my elbow starts to ache badly
• I can’t spike the volleyball anymore
112
Exam Summary:
• Local epicondylar tenderness
• Pain aggravated by resisting wrist extension
• Decreased grip strength
• Full elbow range of motion
113
MEDIAL EPICONDYLITIS
115
Medial Epicondylitis
• CPT: 20551 – Injection of tendon origin or insertion
• ICD 9: 726.31
• ICD 10: M77.0
Patient Symptoms: Medial Epicondylitis
• I losing grip strength, my elbow hurts bad
• After a couple of hours of using my computer, my elbow starts to ache really badly
117
Exam Summary
• Local epicondylar tenderness
• Pain aggravated by resisting wrist flexion and radial deviation
• Decreased grip strength
• Full range of motion of the elbow joint
118
OLECRANON BURSITIS
120
Olecranon Bursitis
• CPT Code: 20605 – Aspiration and/or injection of intermediate bursa
• ICD-9: 726.33
• ICD-10: M70.2
Patient Symptoms: Olecranon Bursitis
• I have this golf ball swelling on the tip of my elbow
• I have got this sack of fluid hanging off my elbow
• All of a sudden, I developed this red, hot , swollen area over my elbow
122
Exam Findings
• Swelling, redness, and heat over the olecranon process
• Full range of motion of the elbow joint
• A characteristic aspirate
123
RADIOHUMERAL JOINT DISEASE
126
127
Patient Symptoms: DJD Elbow
• I can’t straighten my arm
• I feel a pressure buildup in my elbow
• My elbow doesn’t move smoothly anymore. It’s like a ratchet that catches as I try to straighten it
• I can’t throw any more. My elbow hurts too much and it’s getting weaker
128
Exam Summary
• Loss of full flexion, extension, supination or supination
• Lack of smooth motion or catching
• Lateral joint line tenderness and swelling
• Endpoint stiffness or pain
129
RADIAL NERVE ENTRAPMENT
130
Radial Nerve Entrapment: Symptoms
• Caused by entrapment of deep branches of the radial nerve
• Pain, weakness and dysfunction in the distribution of the radial nerve
Exam Findings
• Weakness in the distribution of the radial nerve
– Extensor carpi ulnaris
– Extensor digiti minimi
– Extensor digitorum communis
• Put tenderness at point of entrapment
132
CUBITAL TUNNEL ENTRAPMENTULNAR NERVE
134
Cubital Tunnel Injection
• CPT code: 64450 – injection, nerve block, therapeutic, other peripheral nerve or branch
• ICD-9: 354.2
• ICD-10-G56.2
Patient Symptoms: Cubital Tunnel
• I have numbness in my pinky and ring finger
• I have weakness in my hand
• Every time I hit my elbow, I get an electric shock down my arm
137
Exam: Cubital Tunnel
• Positive Tinel over medial aspect
• Muscle atrophy
• Weakness in distribution of ulnar nerve distal elbow
138
Wrist/Hand
MY WRIST HURTS~
140
Wrist Joint
ICD-9
• Wrist pain: 719.43
• Wrist sprain, unspecified: 842.00
• Wrist joint arthritis: 716.93
• Wrist joint arthrosis, primary: 716.13
• Wrist joint, post-traumatic: 716.13
• Wrist joint arthrosis, secondary: 715.23
ICD-10
• Wrist pain: M25.53
• Wrist sprain, unspecified
S63.5
• Wrist joint arthritis:M13.93
• Wrist joint arthrosis, primary: M19.03
• Wrist joint, post-traumatic
M19.13
• Wrist joint arthrosis, secondary: M19.23
Exam & Findings: Hands/Wrists
• Assess ROM Wrist
– Flexion Extension
– Radial Deviation Ulnar Deviation
Exam & Findings: Hands/Wrists
• Assess ROM Fingers
– MP, PIP, DIP joint flexion/extension
– Finger abduction/adduction
– Thumb opposition
Exam & Findings: Hands/Wrists
• Inspect DIP/PIP joints, MP joints, and wrist joints for:– Contour– Position– Shape– Number/
completeness of digits
– Finger deviation– Swelling
Exam & Findings: Hands/Wrists
• Palpate joints – hand /wrist
– Texture
– Swelling
– Tenderness
– Bogginess
– Nodules
– Bony overgrowths
Hand and Wrist Assessment
• Several procedures are used to evaluate the integrity of the median nerve.
• Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome.
Hand and Wrist Assessment
• Thumb abduction test– Isolates the strength of the abductor
pollicis brevis muscle, innervated only by the median nerve.
• Tinel sign– Tested by striking the patient’s wrist with
your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament.
– Tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign.
Hand and Wrist Assessment
• Phalen test– Patient holds both wrists in a
fully palmarflexed position with the dorsal surfaces pressed together for 1 minute.
– Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome.
DE QUERVAIN TENOSYNOVITIS
152
Patient Symptoms: Dequervains
• I can’t grip anymore
• Every time I pick something up, I get this sharp pain in my wrist
• I have had this sharp pain over my wrist ever since I had an IV started
• I bone is getting bigger – (pointing to the radial styloid)
153
Exam
• Local tenderness at the tip of the radial styloid
• Pain aggravated by resisting thumb extension or abduction
• A positive Finklestein test
• A distensible tenosynovial sac
154
CARPOMETACARPAL OSTEOARTHRITIS(OA)
156
Patient Symptoms: OA Thumb
• I can’t grab anything anymore, my thumbs hurt
• My thumbs are starting to look like the arthritis my grandmother had
• My thumbs feel better if I put pressure on them when I do my work
• I had to stop sewing, knitting or crocheting because of constant pain in my thumbs
157
Patient Symptoms: OA Thumb
• My thumb kills me if I knit too long
• I have this bad ache in the base of my thumb
• I can’t pick things up any more with my thumb and index
• Vibration just kills my thumb
158
Exam
• Compression tenderness across the joint
• Crepitation of the joint in circumduction
• Pain aggravated at the extremes of thumb motions
• Bony deformity, subluxation or both
159
160
GAMEKEEPER’S THUMB
161
Patient Symptoms: Gamekeepers
• I took a fall in the past while skiing. My thumb got caught in my pole strips
• My thumb hurts whenever I try to use a hammer
162
Exam
• Local tenderness and swelling along the ulnar side of the MP joint
• Pain or excessive motion with valgus stress testing of the ulnar collateral ligament
• Decreased pinching strength due to instability or acute pain
163
CARPAL TUNNEL165
Patient Symptoms: Carpal Tunnel
• My thumb and first two fingers go to sleep at night
• My hand keeps going numb
• My hand feels dead. I’ve started dropping things
166
Exam Summary
• Sensory loss in the first three fingers
• Loss of thumb opposition
• Positive Tinel sign, Phalen sign, or both
167
HANDTrigger finger
170
Trigger Finger
• CPT code: 20550- injection of single tendon sheath
• ICD9: 727.03
• ICD10: M65.3
Patient Symptoms: Trigger Digit
• My finger keeps catching
• I wake up in the morning and my finger is locked and very painful to unlock
172
Symptoms
• Local tenderness at the MCP head
• Pain aggravated by stretching the finger in extension
• Mechanical locking of the proximal interphalangeal and or interphalangeal joint of the thumb
173
GANGLION
177
Ganglion
• CPT code: 20550 – injection of ganglion cyst
• ICD9: Ganglion cyst of joint: 727.41
• ICD10: Ganglion cyst of joint: M67.4
• ICD9: Ganglion cyst of tendon sheath: 727.42
• ICD10: Ganglion cyst of tendon: M67.4
Patient Symptoms: Ganglion
• I had this lump on the back of my wrist for a long time but it recently has grown bigger
• My brother in law wanted to hit my wrist with the “Bible” I wouldn’t let him
179
Exam
• Highly mobile, fluctuant cyst that trans illuminates light, min tenderness, normal wrist motion, highly viscous aspirate
180
MY HIP HURTS183
TROCHANTERIC BURSITIS
184
Trochanteric Bursitis
• CPT code: 20551 injection of tendon origin or insertion
• ICD-9 : 726.5
• ICD-10: M70.6
Patient Symptoms: Trochanteric Bursitis
• Whenever I roll over onto my right side, this sharp pain in my hip wakes me up
• I get this aching pain in my hip when I walk to too much in the mall
• I can’t stand for very long
• Climbing up the stairs has become impossible
186
Exam
• Local mid-trochanteric tenderness
• Aggravation of pain at the extremes of hip rotation
• Pain aggravated by resisted hip abduction
• Normal range of motion of the hip
188
OSTEOARTHRITIS OF THE HIP
190
Patient Symptoms: Hip OA
• I have this deep achy pain in my groin whenever I walk too far
• I have to stop and rest every time I stand or walk too long
191
Exam
• Impaired function, loss of normal gait, inability to remove socks, cross the legs, etc.
• Loss of internal and external rotation with endpoint stiffness and pain
192
MY KNEE HURTS~
193
Knee
Legs and Knees
• Inspect.– Landmarks
– Concavities
– Alignment• Valgus ? Varus?
Exam & Findings: Knees
• Palpate supraptellar pouch, femoral epicondyles, on each side of patella , over tibiofemoral joint space and popliteal space for:
– Swelling
– Tenderness
– Bogginess
– Crepitus
Exam & Findings: Knees
• Assess ROM
– Flexion
– Extension
• Assess muscle strength
Exam & Findings: Knee
• McMurray test– Used to detect a torn medial or lateral meniscus
– Flex knee completely, rotate foot to lateral position, and keeping foot in that position, extend the knee to 90 degrees
– Not any palpable or audible clicks, grinding, pain, or limited extension of the knee
– Flex knee again and repeat procedure with food in medial position
McMurray Test
Exam & Findings: Knee
• Anterior drawer test– Used to identify instability of the anterior
– With the patient supine, hips flexed and knees flexed to 90 degrees and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings
– Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur
– Compare both knees – movement greater than 5mm is positive finding
Anterior Drawer Test
Exam & Findings: Knee
• Lachman test– Used to evaluate anterior cruciate ligament integrity
– With the patient supine, flex the knee to 10-15 degrees with the heel on the table
– Place one hand above the knee to stabilize the femur, place the other hand around the proximal tibia
– Pull tibia anteriorly
– Movement greater than 5mm compared to the uninjured side indicates injury to the ligament
Lachman Test
Exam & Findings: Knee
• Posterior drawer test– Used to identify instability of the posterior cruciate
ligament
– Position the patient and place your hands int eh positions described for the anterior drawer test
– Push the tibia posteriorly and observe the degree of backward movement in the femur
– Movement of the knee greater than 5mm is a positive finding
Posterior Drawer Test
Exam & Findings: Knee
• Valgus stress test– Tests the stability of the medial collateral ligament
(MCL)
– With patient supine and knee slightly flexed, move the thigh about 30 degrees laterally to the side of the table
– Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle
– Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side
– Laxity indicates injury to the ligament
Valgus Stress Test
Exam & Findings: Knee• Varus stress test
– Test stability of the lateral collateral ligament (LCL)
– Knee and thigh in same position as for valgus stress test
– Place one hand against the medial surface of the knee and the other around the lateral ankle
– Push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side
– Laxity in this position indicates injury to the meniscus
Varus Stress Test
Exam & Findings: Knee
• Ballottement– Used to determine the presence of excess fluid or an
effusion in the knee
– Knee extended, apply downward pressure to the suprapatellar pouch
– Push the patella sharply against the femur
– If effusion is present, fluid will return to the suprapatellar pouch and the patella will float up when pressure is released
211
Exam & Findings: Knee
• Bulge sign– Test for excess fluid in the knee
– Knee extended, place the left hand above the knee and apply pressure on the supra-patellar pouch, “milking” fluid downward
– Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area
– Tap the knee just behind the lateral margin of the patella with the right hand
– Observe for a bulge of returning fluid to the hollow area medial to the patella
Knee
ICD:9
• Knee pain: 719.46
• Knee sprain, unspecified site
• Knee arthritis, unspecified
• Knee arthrosis, primary
• Knee arthrosis, posttraumatic
• Knee arthrosis, secondary
ICD:10
• Knee pain
• Knee sprain, unspecified site
• Knee arthritis, unspecified
• Knee arthrosis, primary
• Knee arthrosis, posttraumatic
• Knee arthrosis, secondary
PATELLOFEMORAL DISEASE215
Patient Symptoms: Patellofemoral Disease
• My knees always have this grinding sound when I bend
• Kneeling/squatting is just awful
• I have troubles going up/down steps
• My knees give way all the time
• I can’t sit Indian-style anymore
216
Exam Summary
• Painful retro patellar crepitation (squatting, patellar compression)
• Full range of motion but with abnormal patellofemoral tracking
• Negative apprehension sign for patellar dislocation
• Knee effusion - common
217
KNEE EFFUSION
221
Patient Symptoms: Effusion
• My knee is swollen
• I feel an egg behind my knee whenever I bed it back
• My knee is giving out.
• My knee is so swollen I can’t bend it back or fully straighten it.
222
Exam
• General fullness
• Synovial milking sign
• Posterior popliteal swelling
• Patellar ballottement signs
• Supra - patellar bulging
• Needle aspiration
223
OSTEOARTHRITIS KNEE (OA)
227
Patient Symptoms: Knee OA
• My knee gets stiff and painful at the end of the day
• My knees make this awful sound
• I can’t bend or straighten my knees anymore
• When I was 22, I had cartilage removed - now I have a constant ache.
228
Exam Summary
• Joint – line tenderness (medial, lateral, or at the patella)
• Loss of smooth mechanical motion (crepitation)
• Loss of full flexion or extension
• Knee effusion
229
Bursitis
Patient Symptoms: Knee Bursitis
• My knee is swollen
• My have a bump over my knee cap
• I bumped my knee against the kitchen cabinet and within hours it had swollen up.
234
Exam Summary
• Swelling and inflammation directly over the inferior portion of the patella
• Bursa sac tenderness vs bursa sac thickening
• Normal range of motion of the knee unless infection is present.
235
PRE-PATELLAR BURSITIS
236
Prepatellar Bursitis
PES ANSERINE BURSITIS
238
Pes Anserine Busitis
• CPT code: 20551 – Injection of single tendon origin or insertion
• ICD:9 726.61
• ICD:10 M70.5
Patient Symptoms: Pes Anserine
• I have a sharp pain right here – pointing to the inner aspect of the knee)
• I sleep with a pillow between my legs because my knee is tender
• I can’t sleep on my side. When my knees touch, I get his really sharp pain on the inside of my knee
240
Exam Summary
• Local tenderness in the concavity of the medial tibial plateau directly over the tibial tubercle in the midline
• Painless valgus stress testing of the medial collateral ligament
241
BAKERS CYST
242
Patient Symptoms: Bakers Cyst
• I was told that I have a cyst behind my knee
• I have this lump behind my knee
• I was told in the emergency room I may have a blood clot in the back of my knee
243
Exam:
• A cystic mass in the popliteal fossa
• Impaired knee flexion when the cyst is large
• Evidence of current or past chronic knee effusion
• No evidence of peripheral vascular insufficiency or deep venous thrombosis
244
MEDIAL COLLATERAL LIGAMENT SPRAIN
245
Patient Symptoms: MCL
• I sprained my knee when I tripped on the rug
• I was playing touch football when I was tackled from the right side
• I was getting out of the bathtub when my leg caught, my body twisted, and my leg was stretched – hurts on the inside of my knee
246
Exam
• Pain aggravated by valgus stress testing
• Band of local tenderness located between the medial joint line and the insertion on the tibial
• Laxity of the medial collateral ligament
• Associated knee effusion, anterior cruciate ligament tear, or medial meniscal tear
247
LATERAL COLLATERAL LIGAMENT
248
Symptoms: Lateral Collateral
• Swelling pain outside of knee
• Lateral force, falling off horse, sitting on leg, etc.
249
Exam:
• Little effusion
• Lateral knee tenderness
• Pain increased on varus stress
250
MENISCAL TEAR OF THE KNEE251
Symptoms
• My knee locks up whenever I get it in certain bent positions
• My knee catches
• I can’t squat anymore
• If I twist just right, I get this real sharp pain
• Whenever I shift my weight, I felt this loud pop and immediate sharp pain on the inside of my knee
252
Exam
• Loss of smooth motion of the knee
• Inability to squat or kneel
• Palpable popping on the joint line
• Joint effusion
253
ANTERIOR CRUCIATE LIGAMENT INJURY
256
Patient Symptoms: ACL
• I felt a large pop when I got injured playing sports
• My knee really swelled up a great deal
• I think I have a “trick knee” since I injured it a few years ago
• I can’t trust my knee it feels unstable
257
Exam
• Significant effusion
• Positive anterior drawer
• Positive lachman
• Positive pivot shift
258
SIMON SAYS MY ANKLE/FOOT HURTS
259
Ankle/Foot
Exam & Findings: Feet/Ankles
• Inspect
– Contour/position
– Toe deformities
– Alignment
– Weight bearing
– Arch
Feet and Ankles
• Inspect.– Contour and position
– Size and number of toes
– Alignment
– Weight bearing
– Arch
• Palpate.– Heat
– Swelling
– Tenderness
Exam & Findings: Feet/Ankles
• Palpate anterior surface of ankle joint, Achilles tendon, and metatarsal heads for:
– Heat
– Swelling
– Tenderness
• Palpate MTP Joint Compression
Exam & Findings: Feet/Ankles
• Assess ROM
– Dorsiflexion/plantar flexion
– Inversion/eversion
– Abduction/adduction
– Flexion/Extension of toes
• Assess muscle strength
– All the above against resistance
– Flexion/Extension of big toe against resistance
Flexion/Extension of Ankle
Adduction/Abduction of Ankle
Inversion/Eversion of Ankle
ANKLE EFFUSION
268
Symptoms
• I think my ankle is swollen
• My ankle feels tight inside
• I can’t fit in my shoes anymore
269
Exam
• Anterior swelling or general fullness to the ankle
• Anterior joint line tenderness
• Loss of painful plantar flexion or dorsiflexion
• Characteristic aspirate
270
ACHILLES TENDINITIS
272
Patient Symptoms: Achilles
• I have to stop running after two miles because the back of my ankle begins to hurt
• I get a sharp pain through my ankle and up the back of my leg whenever I jump
• My shoes feel like they’re rubbing against the bone
• My Achilles tendon is larger on one side
• I was playing basketball and it felt like somebody kicked me!
274
Exam
• Tenderness and “cobblestone” thickening 1 ½ inches above the calcaneus
• Pain aggravated by stretching in dorsiflexion
• Range of motion of the ankle is otherwise normal
• Strength and tendon integrity are intact
275
POSTERIOR TIBIALISTENOSYNOVITIS
277
Patient Symptoms: Posterior Tibialis
• I have this sharp pain around the inside of my ankle whenever I step
• There is swelling around the back of my ankle
• If I wear tight shoes the inside of my ankle hurts
• My ankle hurts when I’m walking in uneven ground
278
Exam
• Local tenderness and swelling just inferior andposterior to the medial malleolus
• Pain aggravated by resisting ankle inversion and plantar flexion
• Pain aggravated by stretching in eversion
• Normal range of motion of the ankle
279
PLANTAR FASCIITIS
282
Plantar Fasciitis
• CPT code: 20550 – injection of aponeurosis
• ICD 9: 728.71
• ICD10: M72.2
Patient Symptoms: Plantar Fasciitis
• My bottom of my foot kills me in the morning when I first get up
• I can’t stand on concrete surfaces anymore
• I can’t do my jazzercise any more because of my heel pain
284
Physical Exam
• Local tenderness at the calcaneal origin of the plantar fascia
• Pain with calcaneal compression
• Achilles tendon inflexibility
• Tight heel cords
285
HAGLUND’S DEFORMITY
288
Symptoms:
• I have this bump on the back of my heel
• My shoes are always hurting my heel
289
Exam Findings:
• Local tenderness and swelling directly over the posterior calcaneus, normal range of motion
290
Toes
How Many Folks in the Audience Have
UFS????
293
MORTON NEUROMA
296
Morton Interdigital Neuroma
• CPT code: 64450 – Injection, nerve block therapeutic, other peripheral nerve or branch
• ICD-9: 355.6
• ICD-10: G57.6
Symptoms: Neuroma
• My two toes have gone numb, I have sharp pain between my toes
298
Exam Findings
• Maximum tenderness in the web space, pain aggravated by the MTP squeeze sign, loss of sensation along the inner aspects of the adjacent two toes
299
Symptoms: Gout
• I woke up in the night with severe, sharp pain in my big toe, my big toe is very red and swollen
302
Exam Findings
• Acute swelling, redness, and heat arising from the MTP joint, severe tenderness at the MTP joint, pain aggravated by even the slightest movement of the joint
303
THE END!!
Some Extra Stuff!!
305
•
Thank you!
• Any questions/comments please email: Frank Caruso MPS, PAC
References
• Anderson, Bruce. Office Orthopedics for Primary Care Diagnosis and Treatment. Saunders. 1999
• Hoppenfeld, Stanley . Physical Examination of the Spine and Extremities. Appleton-Century Crofts. 1976
• McNabb, James A Practical Guide to Joint and Soft Tissue Injection and Aspiration , 2010. Lippincott Williams and Wilkins. Second Edition
• Saunders, S; Longworth, S. Injection Techniques in Orthopaedics and Sports Medicine 2009. Churchill Livingston – Third Edition
