Advanced Advanced Musculoskeletal Musculoskeletal

ExaminationExamination

Physical Diagnosis IIIPhysical Diagnosis III

Steven Sager, MPAS, PA-CSteven Sager, MPAS, PA-C

Learning ObjectivesLearning Objectives Upon satisfactory completion of this lecture, and Upon satisfactory completion of this lecture, and

in conjunction with textbooks, lecture handouts, in conjunction with textbooks, lecture handouts, WebCT, and recommended internet web sites, the WebCT, and recommended internet web sites, the student will be able to:student will be able to: Review the articular anatomy of the musculoskeletal Review the articular anatomy of the musculoskeletal

systemsystem List the patient history information that will aid in List the patient history information that will aid in

developing a diagnosis for joint disordersdeveloping a diagnosis for joint disorders Review techniques for the standard examination of the Review techniques for the standard examination of the

diarthrosesdiarthroses Identify special techniques of examination of the Identify special techniques of examination of the

diarthrosesdiarthroses Compare and contrast the techniques for evaluating:Compare and contrast the techniques for evaluating:

Fractures, sprains, strains and dislocationsFractures, sprains, strains and dislocations Osteoarthritis and rheumatoid arthritisOsteoarthritis and rheumatoid arthritis TendonitisTendonitis

Perform a thorough examination of the musculoskeletal Perform a thorough examination of the musculoskeletal system using standard and special techniques, as system using standard and special techniques, as appropriateappropriate

Shoulder painShoulder pain Right side:Right side:

Gallbladder diseaseGallbladder disease Peptic ulcerPeptic ulcer Liver abscess/tumorLiver abscess/tumor

Left side:Left side: Acute MIAcute MI PancreatitisPancreatitis Splenic ruptureSplenic rupture

Always consider non-orthopedic etiologies:Always consider non-orthopedic etiologies: Pericarditis – “sharp” chest pain, fever, Pericarditis – “sharp” chest pain, fever,

tachycardia/tachypneatachycardia/tachypnea Myocardial ischemia – HTN, tachycardia, SOB, Myocardial ischemia – HTN, tachycardia, SOB,

syncopesyncope Pulmonary disease – cough, fever, tachypneaPulmonary disease – cough, fever, tachypnea

HPIHPI

Patient’s agePatient’s age Dominant handDominant hand TraumaTrauma OccupationOccupation SportsSports HobbiesHobbies ADLsADLs DysesthesiaDysesthesia

Physical Examination - Physical Examination - ShoulderShoulder

Pertinent positives and negatives for Pertinent positives and negatives for shoulder exam:shoulder exam: edema, erythema, ecchymosis, effusionedema, erythema, ecchymosis, effusion stiffness, “clicking” stiffness, “clicking” instabilityinstability deformitydeformity

winging winging tenderness (where?) tenderness (where?)

bursitis (inflammatory, septic, DJD) bursitis (inflammatory, septic, DJD) rhomboid vs. trapezius spasm rhomboid vs. trapezius spasm shoulder girdle, axilla, and clavicle status shoulder girdle, axilla, and clavicle status ? AC separation ? AC separation ? shoulder dislocation ? shoulder dislocation

ROM and muscle strength ROM and muscle strength (active/passive) (active/passive)

Active movement through the arcActive movement through the arc ““clicking” = tear of the glenoid clicking” = tear of the glenoid

labrum or glenohumeral capsulelabrum or glenohumeral capsule Instability = rotator cuff tearInstability = rotator cuff tear Limitations:Limitations:

active & passive = adhesive capsilitis & active & passive = adhesive capsilitis & fracturefracture

active only = rotator cuff tearactive only = rotator cuff tear

Case StudyCase Study 14y.o. female c/o “deformed” right shoulder. 14y.o. female c/o “deformed” right shoulder.

Denies trauma. Parents noted protuberant back Denies trauma. Parents noted protuberant back bones at age 4 during gymnastics. Denies upper bones at age 4 during gymnastics. Denies upper extremity weaknessextremity weakness

Dx?Dx?

Specialty testing of the Specialty testing of the ShoulderShoulder

Apley scratch testApley scratch test Apprehension testApprehension test Sulcus testSulcus test Yeargersons testYeargersons test Rotator cuff impingement testRotator cuff impingement test

flexion-internal rotation testflexion-internal rotation test Drop arm testDrop arm test Supraspinatus strength testSupraspinatus strength test

““empty can test”empty can test” Cross chest testCross chest test

horizontal adduction testhorizontal adduction test Speed’s testSpeed’s test Dugas’ testDugas’ test

Apley Scratch TestApley Scratch Test

Abduction and External RotationAbduction and External Rotation ask the patient to reach behind his or her ask the patient to reach behind his or her

head and touch the superior medial angle head and touch the superior medial angle of the opposite scapula.of the opposite scapula.

Adduction and Internal RotationAdduction and Internal Rotation instruct the patient to reach back and touch instruct the patient to reach back and touch

the inferior angle of the opposite scapula .the inferior angle of the opposite scapula . you may also assess adduction and internal you may also assess adduction and internal

rotation by having the patient reach in front rotation by having the patient reach in front and touch the opposite acromion process.and touch the opposite acromion process.

Document the level of thoracic Document the level of thoracic vertebrae reached. vertebrae reached. **

Apprehension TestApprehension Test Position the patient supine in a relaxed Position the patient supine in a relaxed

position on the examination table.position on the examination table. Support the patient's arm with the Support the patient's arm with the

shoulder abducted 90 degrees and the shoulder abducted 90 degrees and the elbow flexed 90 degrees.elbow flexed 90 degrees.

While supporting the humerus at the elbow While supporting the humerus at the elbow with one hand, grasp the patient's forearm with one hand, grasp the patient's forearm with your other hand.with your other hand.

Gently and gradually externally rotate the Gently and gradually externally rotate the shoulder.shoulder. if the patient has had a recent anterior if the patient has had a recent anterior

dislocation or subluxation of the glenohumeral dislocation or subluxation of the glenohumeral joint, apprehension or discomfort will occur as joint, apprehension or discomfort will occur as the shoulder approaches 90 degrees of external the shoulder approaches 90 degrees of external rotation.rotation.

Be careful not to cause an actual anterior Be careful not to cause an actual anterior dislocation when externally rotating the dislocation when externally rotating the arm. **arm. **

Sulcus TestSulcus Test Have the patient stand with the involved Have the patient stand with the involved

arm hanging relaxed at the side.arm hanging relaxed at the side. Ask the patient to use the unaffected hand Ask the patient to use the unaffected hand

to grasp the wrist of the involved arm.to grasp the wrist of the involved arm. Apply a downward directed, distractive Apply a downward directed, distractive

force on the involved arm and palpate the force on the involved arm and palpate the space between the humeral head and the space between the humeral head and the undersurface of the acromion.undersurface of the acromion. note any indentions (sulcus) on the top of the note any indentions (sulcus) on the top of the

mid-deltoid as the humeral head subluxes mid-deltoid as the humeral head subluxes inferiorly.inferiorly.

You should also perform this test on the You should also perform this test on the uninvolved shoulder, comparing bilaterally. uninvolved shoulder, comparing bilaterally. ****

Examination of the Examination of the Rotator CuffRotator Cuff

““SITS” musclesSITS” musclespassively extend the shoulderpassively extend the shoulder

palpate over the greater tuberosity of palpate over the greater tuberosity of the humerusthe humerus

abduct against resistanceabduct against resistance““drop arm” signdrop arm” sign

adduct against resistanceadduct against resistance internally rotate against internally rotate against resistanceresistance

externally rotate against externally rotate against resistanceresistance

Rotator Cuff Impingement TestRotator Cuff Impingement Test(flexion-internal rotation test)(flexion-internal rotation test)

Stand to the side of the patient's involved Stand to the side of the patient's involved shoulder and grasp the patient's elbow with shoulder and grasp the patient's elbow with one hand and support the arm so that both one hand and support the arm so that both the elbow and shoulder are flexed 90 the elbow and shoulder are flexed 90 degrees.degrees.

Place your other hand on the patient's Place your other hand on the patient's forearm and maximally, internally rotate forearm and maximally, internally rotate the humerus.the humerus. this passive movement drives the greater this passive movement drives the greater

tuberosity under the coracoacromial arch and tuberosity under the coracoacromial arch and impinges the rotator cuff.impinges the rotator cuff.

This movement will elicit a painful response This movement will elicit a painful response if rotator cuff inflammation or impingement if rotator cuff inflammation or impingement syndrome is present.syndrome is present.

You should also perform this test on the You should also perform this test on the uninvolved shoulder and compare uninvolved shoulder and compare bilaterally. **bilaterally. **

Drop Arm TestDrop Arm Test(Supraspinatus Test)(Supraspinatus Test)

Place the arm to be tested at 90 degrees Place the arm to be tested at 90 degrees abduction abduction internally rotate the arminternally rotate the arm try to slowly lower the arm to the sidetry to slowly lower the arm to the side

Have the patient maintain this arm Have the patient maintain this arm position as you tap down on the forearm.position as you tap down on the forearm. if there is a tear of the supraspinatus tendon, if there is a tear of the supraspinatus tendon,

the arm will drop because of weakness or the arm will drop because of weakness or pain.pain.

Codman’s test/signCodman’s test/sign

Supraspinatus Strength TestSupraspinatus Strength Test(The Empty Can Test)(The Empty Can Test)

The patient stands with both arms in 90 The patient stands with both arms in 90 degrees of abduction, 30 degrees of horizontal degrees of abduction, 30 degrees of horizontal adduction and full internal rotationadduction and full internal rotation

Ask the patient to maintain this position.Ask the patient to maintain this position. Place your hands on the superior aspect of the Place your hands on the superior aspect of the

elbow and press downward.elbow and press downward. Compare the patient's ability to resist your Compare the patient's ability to resist your

downward pressure with both the involved and downward pressure with both the involved and uninvolved shoulders.uninvolved shoulders. decreased ability of the involved shoulder to resist decreased ability of the involved shoulder to resist

your downward pressure as compared to the your downward pressure as compared to the uninvolved shoulder is indicative of supraspinatus uninvolved shoulder is indicative of supraspinatus weakness.weakness.

This test may also elicit pain, indicating This test may also elicit pain, indicating inflammation and muscle weakness. **inflammation and muscle weakness. **

Cross Chest Or Horizontal Cross Chest Or Horizontal Adduction TestAdduction Test

Assesses acromioclavicular joint impingementAssesses acromioclavicular joint impingement With the patient supine or standing, grasp With the patient supine or standing, grasp

the distal humerus with one hand and the distal humerus with one hand and position it in 90 degrees of abduction.position it in 90 degrees of abduction.

Passively move the humerus across the chest.Passively move the humerus across the chest. As the humerus approaches full horizontal As the humerus approaches full horizontal

adduction, question the patient regarding adduction, question the patient regarding pain in the acromioclavicular joint.pain in the acromioclavicular joint.

Lightly place the fingers of your other hand Lightly place the fingers of your other hand over the acromioclavicular joint to palpate for over the acromioclavicular joint to palpate for crepitus and separation.crepitus and separation. this procedure compresses (impinges) the this procedure compresses (impinges) the

acromioclavicular joint and is painful if internal acromioclavicular joint and is painful if internal derangement or instability exist.derangement or instability exist.

Perform this test on the uninvolved shoulder Perform this test on the uninvolved shoulder and compare bilaterally. **and compare bilaterally. **

Speed’s TestSpeed’s Test Used to assess the integrity of the Used to assess the integrity of the

biceps tendon.biceps tendon. Arm is extended behind and the Arm is extended behind and the

forearm supinated with elbow forearm supinated with elbow slightly flexed.slightly flexed.

Examiner resists shoulder forward Examiner resists shoulder forward flexion by the patient while the flexion by the patient while the patient’s arm is supinated and the patient’s arm is supinated and the elbow is completely extended.elbow is completely extended.

Positive test elicits increased Positive test elicits increased tenderness in the bicipital groove tenderness in the bicipital groove and indicates bicipital tendonitis.and indicates bicipital tendonitis.

Adson ManeuverAdson Maneuver Test for Thoracic Outlet SyndromeTest for Thoracic Outlet Syndrome Patient’s head is rotated to face Patient’s head is rotated to face

the tested shoulder.the tested shoulder. Patient then extends the head Patient then extends the head

while the examiner laterally rotates while the examiner laterally rotates and extends the patient’s shoulder.and extends the patient’s shoulder.

Examiner locates radial pulse and Examiner locates radial pulse and the patient is instructed to take a the patient is instructed to take a deep breath and hold it.deep breath and hold it.

Disappearance of pulse is Disappearance of pulse is indicative of a positive test.indicative of a positive test.

Clinical FindingsClinical Findings DislocationDislocation

Rotator Cuff TearRotator Cuff Tear common cause of pain and weakness in the shouldercommon cause of pain and weakness in the shoulder frequent use of the hands in the overhead position causes frequent use of the hands in the overhead position causes

inflammation, pain, and tenderness in the tendons and inflammation, pain, and tenderness in the tendons and ligaments eventually weakening the rotator cuff resulting in ligaments eventually weakening the rotator cuff resulting in tears of the tendons.tears of the tendons.

traumatic teartraumatic tear = a direct blow to the shoulder, a fall onto = a direct blow to the shoulder, a fall onto an outstretched hand, or a dislocated shoulder joint results in an outstretched hand, or a dislocated shoulder joint results in a tear of one of the rotator cuff tendons.a tear of one of the rotator cuff tendons.

degenerative teardegenerative tear = a process of natural wear and tear = a process of natural wear and tear breaks down the strength and flexibility of the rotator cuff breaks down the strength and flexibility of the rotator cuff tendons, leading to a complete rupture of one of the tendons.tendons, leading to a complete rupture of one of the tendons.

Backpack palsyBackpack palsy Brachial plexus overpull caused by a heavy backpack’s Brachial plexus overpull caused by a heavy backpack’s

shoulder straps resulting in palsy along the 5shoulder straps resulting in palsy along the 5thth and 6 and 6thth cervical nerve distributioncervical nerve distribution

Which of the following Which of the following tests/signs is not specific tests/signs is not specific for a tear of the rotator for a tear of the rotator

cuff?cuff?

0%

0%

0%

0%

0% 1.1. Speeds testSpeeds test

2.2. Codman signsCodman signs

3.3. Empty can testEmpty can test

4.4. Sulcus signSulcus sign

5.5. Drop arm testDrop arm test

Physical Examination – Upper Physical Examination – Upper ExtremityExtremity

Pertinent positives and negatives for Pertinent positives and negatives for elbow/hand exam:elbow/hand exam: edema, erythema, ecchymosis, effusion edema, erythema, ecchymosis, effusion deformitydeformity crepituscrepitus tenderness: (where?)tenderness: (where?)

bursitis (inflammatory, septic) bursitis (inflammatory, septic) snuff boxsnuff box tendonitis/tenosynovitis (inflammatory, infectious) tendonitis/tenosynovitis (inflammatory, infectious) sprain, strain, fracturesprain, strain, fracture

Fx (volar plate, boxer's, Bennett's, Colle's, nightstick)Fx (volar plate, boxer's, Bennett's, Colle's, nightstick) overuse syndrome overuse syndrome ROM (active/passive) ROM (active/passive) muscle strength (active/passive) muscle strength (active/passive)

flexor and extensor tendon integrity flexor and extensor tendon integrity nodules/cystsnodules/cysts

Clinical FindingsClinical Findings Olecranon bursitisOlecranon bursitis

localized edema over the olecranon processlocalized edema over the olecranon process

Lateral Humeral epicondylitisLateral Humeral epicondylitis tenderness over the lateral epicondyletenderness over the lateral epicondyle

Radial head fractureRadial head fracture tenderness in lateral antecubital fossatenderness in lateral antecubital fossa tenderness distal to the lateral humeral epicondyletenderness distal to the lateral humeral epicondyle

Nursemaid’s elbowNursemaid’s elbow traction injury to a child’s forearm resulting in traction injury to a child’s forearm resulting in

anterior and superior dislocation of the radial headanterior and superior dislocation of the radial head

Tennis Elbow TestTennis Elbow Test

Stabilize the forearmStabilize the forearm

Instruct the patient to make a fist Instruct the patient to make a fist and extend the wristand extend the wrist

Examiner provides resistanceExaminer provides resistance

Positive if sudden, sharp pain at Positive if sudden, sharp pain at epicondyleepicondyle

Clinical findingsClinical findings

Clinical findingsClinical findings

Special Testing of theSpecial Testing of theWrist and HandWrist and Hand

Scaphoid Compression TestScaphoid Compression Test

Finkelstein's TestFinkelstein's Test

Phalen’s TestPhalen’s Test

Tinel's TestTinel's Test

Allen testAllen test

Scaphoid Compression Scaphoid Compression TestTest

The patient should rest the involved forearm on the The patient should rest the involved forearm on the table.table.

Ask the patient to extend the thumb so that these Ask the patient to extend the thumb so that these tendons become prominent.tendons become prominent. the anatomical snuff box is formed by space between the the anatomical snuff box is formed by space between the

abductor pollicis longus and extensor pollicis brevis tendons abductor pollicis longus and extensor pollicis brevis tendons on the radial border and the extensor pollicis longus tendon on on the radial border and the extensor pollicis longus tendon on the ulna side.the ulna side.

The examiner presses in the anatomical snuffbox, The examiner presses in the anatomical snuffbox, applying compression to the scaphoid navicular bone.applying compression to the scaphoid navicular bone.

Pain with palpation of the snuffbox is indicative of a Pain with palpation of the snuffbox is indicative of a scaphoid fracture, particularly if the patient also has scaphoid fracture, particularly if the patient also has pain in the same area with passive wrist pain in the same area with passive wrist hyperextension.hyperextension.

Finkelstein's TestFinkelstein's Test Determines presence of De Quervain's Determines presence of De Quervain's

tenosynovitis or Hoffman's disease in the tenosynovitis or Hoffman's disease in the abductor pollicis longus and the extensor abductor pollicis longus and the extensor pollicis brevis tendons of the thumb.pollicis brevis tendons of the thumb.

Technique:Technique: patient sits with the forearm supported on the table patient sits with the forearm supported on the table

in a neutral position.in a neutral position. the hand should be free to hang over the table edge.the hand should be free to hang over the table edge. instruct the patient to make a fist with the thumb instruct the patient to make a fist with the thumb

inside the fingers, deviating the wrist to the ulnar inside the fingers, deviating the wrist to the ulnar side.side.

the examiner can accentuate the test by using one the examiner can accentuate the test by using one hand to stabilize the distal forearm while placing hand to stabilize the distal forearm while placing your other hand over the fist's radial side to push your other hand over the fist's radial side to push the wrist into further ulnar deviation. **the wrist into further ulnar deviation. **

Phalen’s TestPhalen’s Test Detects Carpal Tunnel SyndromeDetects Carpal Tunnel Syndrome

Technique:Technique: instruct the patient to flex both shoulders and instruct the patient to flex both shoulders and

elbows approximately 90 degrees.elbows approximately 90 degrees. then ask the patient to flex both wrists so that the then ask the patient to flex both wrists so that the

dorsal surface of both hands can be placed dorsal surface of both hands can be placed against one another.against one another.

hold this maximally flexed position for at least hold this maximally flexed position for at least one minuteone minute

After approximately one minute, tingling or After approximately one minute, tingling or numbness in the median nerve distribution numbness in the median nerve distribution over the involved palmar surface indicates over the involved palmar surface indicates the presence of carpal tunnel syndrome.the presence of carpal tunnel syndrome.

Tinel's SignTinel's Sign

Detects Carpal Tunnel SyndromeDetects Carpal Tunnel Syndrome

Technique:Technique: position the patient with the forearm in supination position the patient with the forearm in supination

and the hand relaxed on the table surfaceand the hand relaxed on the table surface use your index finger to tap over the carpal tunnel use your index finger to tap over the carpal tunnel

at the wristat the wrist

A positive test results when the tapping causes A positive test results when the tapping causes tingling or paresthesia in the area of the tingling or paresthesia in the area of the median nerve distribution, which includes the median nerve distribution, which includes the middle finger and lateral half of the ring middle finger and lateral half of the ring finger.finger.

Clinical FindingsClinical Findings Boutonnière’s deformityBoutonnière’s deformity

tear injury to the extensor mechanism of the tear injury to the extensor mechanism of the finger resulting in a fixed deformity that consists finger resulting in a fixed deformity that consists of flexion of the PIP joint and extension of the of flexion of the PIP joint and extension of the DIP jointDIP joint

Mallet fingerMallet finger injury to the extensor mechanism of the finger at injury to the extensor mechanism of the finger at

the DIP jointthe DIP joint Swan-neck deformitySwan-neck deformity

hyperextension injury to the PIP joint of the hyperextension injury to the PIP joint of the finger resulting in hyperextension of the PIP joint finger resulting in hyperextension of the PIP joint and flexion of the DIP jointand flexion of the DIP joint

Trigger fingerTrigger finger inflammation of the flexor tendon and synovial inflammation of the flexor tendon and synovial

sheath causing the finger to “catch” as it extendssheath causing the finger to “catch” as it extends

Clinical FindingsClinical Findings

Gamekeeper’s thumbGamekeeper’s thumb partial subluxation and instability of the partial subluxation and instability of the

thumb at the MCP joint caused by thumb at the MCP joint caused by rupture of the ulnar collateral ligamentrupture of the ulnar collateral ligament

Jersey fingerJersey finger avulsion of the flexor tendon of the 4avulsion of the flexor tendon of the 4thth

or 5or 5thth finger finger

Case StudyCase Study

48-year-old female complains of finger 48-year-old female complains of finger and knuckle pain in the MCP and PIP of and knuckle pain in the MCP and PIP of the index and middle fingers in her the index and middle fingers in her right hand x1 year. She is RHD. Recent right hand x1 year. She is RHD. Recent exacerbation. AM stiffness and stuck in exacerbation. AM stiffness and stuck in flexion at the PIP joint. Decreased grip. flexion at the PIP joint. Decreased grip. No trauma. No dysesthesias. No trauma. No dysesthesias.

PMH: uncontrolled NIDDM, arthritis PMH: uncontrolled NIDDM, arthritis and adhesive capsilitis in R shoulderand adhesive capsilitis in R shoulder

Case StudyCase Study VSSVSS 1+ edema over MCP joints of 1+ edema over MCP joints of

right index and middle fingersright index and middle fingers Motor and sensory are intactMotor and sensory are intact

Additional tests?Additional tests?

Dx?Dx?

Tx?Tx?

Physical Examination - Physical Examination - KneeKnee

Pertinent positives and negatives for knee Pertinent positives and negatives for knee exam:exam: edema, erythema, ecchymosis, effusion edema, erythema, ecchymosis, effusion deformity/malalignmentdeformity/malalignment stabilitystability

valgus (med collateral) valgus (med collateral) varus (lat collateral) varus (lat collateral) anterior drawer (anterior cruciate) anterior drawer (anterior cruciate) posterior drawer (posterior cruciate) posterior drawer (posterior cruciate) Lachman's (ACL) Lachman's (ACL) posterior sag (PCL) posterior sag (PCL)

massesmasses tendernesstenderness

patellar grind (PFS, CMP) patellar grind (PFS, CMP)

Physical Examination - Physical Examination - KneeKnee

Pertinent positives and negatives for Pertinent positives and negatives for knee exam:knee exam: ballotment, bulge sign (effusion) ballotment, bulge sign (effusion) McMurray's (meniscus) McMurray's (meniscus) Apley's compression (meniscus) Apley's compression (meniscus) Apley's distraction (collaterals) Apley's distraction (collaterals) Tinel sign (neuromata) Tinel sign (neuromata) ROM (active/passive) ROM (active/passive) muscle strength (active/passive) muscle strength (active/passive) neurovascular check (L4, L5, S1) - sensory neurovascular check (L4, L5, S1) - sensory

specific specific

Clinical FindingsClinical Findings

Genu valgumGenu valgum malalignment of the knees medially; “knock-malalignment of the knees medially; “knock-

kneed”kneed”

Genu varumGenu varum malalignment of the knees laterally; “bow-malalignment of the knees laterally; “bow-

legged”legged”

Housemaid’s kneeHousemaid’s knee prepatellar bursitis caused by prolonged prepatellar bursitis caused by prolonged

kneelingkneeling

Clinical findingsClinical findings

Special testing of The Special testing of The KneeKnee

patellar movementpatellar movement patellar compression testpatellar compression test palpate the prepatellar bursapalpate the prepatellar bursa valgus stressvalgus stress varus stressvarus stress ballottementballottement drawer sign (anterior & posterior)drawer sign (anterior & posterior) Lachman testLachman test McMurray testMcMurray test Apley’s testApley’s test

BallottementBallottement Used to assess for fluid/effusion in the kneeUsed to assess for fluid/effusion in the knee

Technique:Technique: knee extendedknee extended apply downward pressure on the suprapatellar apply downward pressure on the suprapatellar

pouchpouch push the patella sharply downwardpush the patella sharply downward

If an effusion is present:If an effusion is present: tapping or clicking will be felt when the patella tapping or clicking will be felt when the patella

strikes the femurstrikes the femur the patella will “float” outward when pressure is the patella will “float” outward when pressure is

releasedreleased

Drawer TestDrawer Test Used to assess anterior and posterior cruciate Used to assess anterior and posterior cruciate

ligament injuryligament injury

Technique:Technique: position the patient with the knee flexed 90 degrees, position the patient with the knee flexed 90 degrees,

the lower leg in neutral rotation, and the hip flexed the lower leg in neutral rotation, and the hip flexed to 45 degreesto 45 degrees

the examiner medially rotates the patients foot the examiner medially rotates the patients foot slightly and sits on the foot to stabilize itslightly and sits on the foot to stabilize it

examiner pushes and pulls on the tibiaexaminer pushes and pulls on the tibia

The test is positive if tibia moves or rotates an The test is positive if tibia moves or rotates an excessive amount compared to the normal excessive amount compared to the normal knee.knee.

Lachman’s TestLachman’s Test Used to evaluate the anterior cruciate Used to evaluate the anterior cruciate

ligament (ACL)ligament (ACL)

Technique:Technique: patient supinepatient supine flex knee 0-30°, keep heel on the tableflex knee 0-30°, keep heel on the table stabilize the femur just above the kneestabilize the femur just above the knee pull the proximal tibia anteriorlypull the proximal tibia anteriorly

Increased laxity (>5 mm) indicates Increased laxity (>5 mm) indicates ACL injuryACL injury

McMurray’s TestMcMurray’s Test Place the knee in full flexion.Place the knee in full flexion.

The foot is held in one hand while the The foot is held in one hand while the other hand palpates the joint line on other hand palpates the joint line on both sides of the knee.both sides of the knee.

A click or grinding may indicate a A click or grinding may indicate a tear of the posterior segment of the tear of the posterior segment of the meniscus while flexing and extending meniscus while flexing and extending the knee. ** the knee. **

Apley’s TestApley’s Test Used to assess the knee for:Used to assess the knee for:

medial or lateral menisci injurymedial or lateral menisci injury internal derangementinternal derangement

osteochondritis dissecansosteochondritis dissecans osteochondral fractures.osteochondral fractures.

Technique:Technique: patient prone with knee in 90° flexionpatient prone with knee in 90° flexion pressure is then applied to the heel pressure is then applied to the heel

while the foot is rotatedwhile the foot is rotated ****

Case StudyCase Study

17y.o. female presents with localized, 17y.o. female presents with localized, constant “sharp” left knee pain (8/10) constant “sharp” left knee pain (8/10) since last night. Acute onset with ? since last night. Acute onset with ? instability secondary to a “stop and instability secondary to a “stop and twist” injury while playing flag twist” injury while playing flag football. No audible pop. Immediate football. No audible pop. Immediate edema which has worsened. Tx with edema which has worsened. Tx with ice at scene. Increased pain with ice at scene. Increased pain with ambulation. No relief with OTC ambulation. No relief with OTC meds. NWB with crutches.meds. NWB with crutches.

Case Study (cont.)Case Study (cont.) Physical examination reveals 3+ periarticular Physical examination reveals 3+ periarticular

edema in the left knee. AROM is limited to edema in the left knee. AROM is limited to 70° flexion and -10° extension. No laxity on 70° flexion and -10° extension. No laxity on varus/valgus stress. Unable to perform other varus/valgus stress. Unable to perform other tests due to pain.tests due to pain.

Which of the following knee tests would you Which of the following knee tests would you expect to be positive?expect to be positive? LachmanLachman McMurrayMcMurray Drawer testDrawer test Apley’sApley’s None of the aboveNone of the above

What’s next?What’s next?

Case Study (cont.)Case Study (cont.)

Key points:Key points: mechanism of injurymechanism of injury absence of “pop”absence of “pop” acute swellingacute swelling inability to bear weightinability to bear weight

Clinical findingsClinical findings

Clinical findingsClinical findings

Clinical findingsClinical findings

Examination of The Ankle Examination of The Ankle and Footand Foot

Inspect the ankles and feet for:Inspect the ankles and feet for: symmetrysymmetry deformitydeformity

look for pes planus and pes cavuslook for pes planus and pes cavus signs of inflammation and edemasigns of inflammation and edema

Palpate:Palpate: gastrocnemius & soleus musclesgastrocnemius & soleus muscles Achilles tendonAchilles tendon tarsals, metatarsals, phalangestarsals, metatarsals, phalanges MTP, PIP and DIP jointsMTP, PIP and DIP joints

Flex and extend the toesFlex and extend the toes isolate the joints by stabilizing the ankleisolate the joints by stabilizing the ankle

Physical exam – Physical exam – Ankle/footAnkle/foot

Pertinent Positives and Negatives for Pertinent Positives and Negatives for ankle exam:ankle exam: edema, ecchymosis, erythema, effusion edema, ecchymosis, erythema, effusion lesions, rashes, masses, nodules. lesions, rashes, masses, nodules. deformitydeformity

syndesmosis disruptionsyndesmosis disruption tendernesstenderness

plantar fascia plantar fascia metatarsal squeeze test (Morton's neuroma) metatarsal squeeze test (Morton's neuroma) Achilles squeeze testAchilles squeeze test bursitis (inflammatory, septic) bursitis (inflammatory, septic) fractures (Jones, Pott's, talar dome)fractures (Jones, Pott's, talar dome)

Physical exam – Physical exam – Ankle/footAnkle/foot

Pertinent Positives and Negatives for Pertinent Positives and Negatives for ankle exam:ankle exam: crepitus (where?) crepitus (where?) stabilitystability

ATFL, CFL, PTFL, deltoid ligamentATFL, CFL, PTFL, deltoid ligament anterior draweranterior drawer

ROM (active/passive)ROM (active/passive) muscle strength (active/passive) muscle strength (active/passive) neurological - sensory specific neurological - sensory specific vascularvascular Homan's test (DVT) Homan's test (DVT)

Evaluation of ankle sprains, Evaluation of ankle sprains, strains, & fracturesstrains, & fractures

A definitive evaluation of all sprains is A definitive evaluation of all sprains is important to R/O fractureimportant to R/O fracture

Sprains:Sprains: partial or complete tear of the ligamentspartial or complete tear of the ligaments graded 1-3graded 1-3 most common injury of the anklemost common injury of the ankle inversion sprains make up the majorityinversion sprains make up the majority eversion sprains may be more severe due eversion sprains may be more severe due

to their association with syndesmosis to their association with syndesmosis injuries.injuries.

Evaluation of ankle sprains, Evaluation of ankle sprains, strains, & fracturesstrains, & fractures

Record a history of the cause of the Record a history of the cause of the injury. injury. Ascertain the type of trauma:Ascertain the type of trauma:

inversion/eversioninversion/eversion dorsiflexion/plantarflexiondorsiflexion/plantarflexion

Determine whether the problem is acute, Determine whether the problem is acute, subacute, chronic, or of insidious onset. subacute, chronic, or of insidious onset.

Determine the severity and specific Determine the severity and specific anatomic location of the painanatomic location of the pain

Document any present medication(s)Document any present medication(s) Document any history of systemic Document any history of systemic

disease or previous ankle injury or disease or previous ankle injury or disabilitydisability

Evaluation of ankle sprains, Evaluation of ankle sprains, strains, & fracturesstrains, & fractures

Physical Examination:Physical Examination: Assess the ability of the patient to bear Assess the ability of the patient to bear

weight, from no to full weight-bearing weight, from no to full weight-bearing abilityability

Inspect for any evidence of an open or Inspect for any evidence of an open or penetrating woundpenetrating wound

Test the range-of-motion of the jointTest the range-of-motion of the joint Inspect for:Inspect for:

deformitydeformity tendernesstenderness ecchymosisecchymosis associated nerve, neurovascular, or tendon associated nerve, neurovascular, or tendon

injuryinjury

Evaluation of ankle sprains, Evaluation of ankle sprains, strains, & fracturesstrains, & fractures

Physical Examination: (cont.)Physical Examination: (cont.) evaluate for evidence of joint instabilityevaluate for evidence of joint instability search for any evidence of dislocation or search for any evidence of dislocation or

arterial vascular compromisearterial vascular compromise cold, dusky foot with loss of sensation, pulse, cold, dusky foot with loss of sensation, pulse,

and possibly sensationand possibly sensation if found, an immediate reduction should take if found, an immediate reduction should take

place (prior to x-rays if necessary)place (prior to x-rays if necessary)

X-ray the ankle (two views)X-ray the ankle (two views) only if a fracture is suspected!only if a fracture is suspected! special views such as mortise should be special views such as mortise should be

obtained when necessaryobtained when necessary

Case StudyCase Study S:S: A 20-month-old toddler presents to the A 20-month-old toddler presents to the

emergency department. Her parents state that emergency department. Her parents state that she has been refusing to actively bear weight she has been refusing to actively bear weight on her left leg for the last 3 hours. The child on her left leg for the last 3 hours. The child has attempted to walk during this period, but has attempted to walk during this period, but she has a noticeable limp and favors the she has a noticeable limp and favors the affected leg. The patient no history of fever, affected leg. The patient no history of fever, and her parents deny any history of observed and her parents deny any history of observed trauma.trauma.

Additional history?Additional history?

BP 114/70 mm Hg; HR: 132 bpm, regular; RR: BP 114/70 mm Hg; HR: 132 bpm, regular; RR: 24 breaths/min, no distress; Temp: 37°C A.D.24 breaths/min, no distress; Temp: 37°C A.D.

Case StudyCase Study O:O:

Well-developed toddler in mild distress. Alert Well-developed toddler in mild distress. Alert and cooperative. Slowly ambulates with an and cooperative. Slowly ambulates with an antalgic gait. Her neck is supple without antalgic gait. Her neck is supple without nuchal rigidity. Cardiac, respiratory, and nuchal rigidity. Cardiac, respiratory, and abdominal findings are unremarkable.abdominal findings are unremarkable.She has no evidence of erythema or warmth on She has no evidence of erythema or warmth on the skin, no definite areas of tenderness, and the skin, no definite areas of tenderness, and no other evidence of trauma such as abrasions no other evidence of trauma such as abrasions or lacerations. The patient is noted to have or lacerations. The patient is noted to have good range of motion of all joints in her good range of motion of all joints in her extremities without obvious deformity or joint extremities without obvious deformity or joint effusion. When the patient is asked to walk, effusion. When the patient is asked to walk, she reluctantly attempts to take a few steps she reluctantly attempts to take a few steps but does not fully bear weight on her left leg.but does not fully bear weight on her left leg.

Laboratory results, including a CBC and an Laboratory results, including a CBC and an ESR, are WNL.ESR, are WNL.

Case Case studystudy

Additional tests?Additional tests?

Diagnosis?Diagnosis?

Treatment?Treatment?

Clinical FindingsClinical Findings Pump bump (Haglund’s deformity)Pump bump (Haglund’s deformity)

thickening on the posterosuperior aspect of the thickening on the posterosuperior aspect of the calcaneuscalcaneus

HammertoeHammertoe flexion deformity of the PIP joint on the 2flexion deformity of the PIP joint on the 2ndnd

through 5through 5thth toes causing hyperextension of the toes causing hyperextension of the MTP jointMTP joint

patients typically develop a boney prominence patients typically develop a boney prominence on the dorsum of the PIP jointon the dorsum of the PIP joint

Turf toeTurf toe Hyperextension of the MTP joint of the great toe Hyperextension of the MTP joint of the great toe

with possible tearing of the flexor tendonwith possible tearing of the flexor tendon

Anatomy of a Anatomy of a Bunion (Hallux Bunion (Hallux

Valgus)Valgus)

Recording the resultsRecording the results Upright posture with a steady gait; fully weight Upright posture with a steady gait; fully weight

bearing; no visible or palpable deformity; spine bearing; no visible or palpable deformity; spine is midline with normal lordotic and kyphotic is midline with normal lordotic and kyphotic curvatures; no paravertebral tenderness; curvatures; no paravertebral tenderness; symmetrical muscle bulk and tone; grip strength symmetrical muscle bulk and tone; grip strength is equal; strength is 5/5 bilaterally in upper and is equal; strength is 5/5 bilaterally in upper and lower extremities; all joints are symmetrical and lower extremities; all joints are symmetrical and non-tender; no joint effusions, erythema, non-tender; no joint effusions, erythema, clubbing, cyanosis or edema; no crepitus on clubbing, cyanosis or edema; no crepitus on palpation; Full AROM/PROM in all joints; no palpation; Full AROM/PROM in all joints; no ligamentous laxity; bilateral knee examination ligamentous laxity; bilateral knee examination reveals patella is midline and freely moveable; reveals patella is midline and freely moveable; no joint margin tenderness is present; no laxity no joint margin tenderness is present; no laxity with varus /valgus stress; anterior/posterior with varus /valgus stress; anterior/posterior drawer sign is negative; drawer sign is negative; Lachman’s/McMurray’s/Apley’s tests are Lachman’s/McMurray’s/Apley’s tests are negative.negative.

Health PromotionHealth Promotion Balanced nutritionBalanced nutrition

calciumcalcium Regular exerciseRegular exercise

maintains (? increases) bone massmaintains (? increases) bone mass stress managementstress management disease preventiondisease prevention

Maintain appropriate weightMaintain appropriate weight reduces mechanical wear on jointsreduces mechanical wear on joints

Household/occupational safetyHousehold/occupational safety Proper liftingProper lifting Fall preventionFall prevention

Injury to the extensor Injury to the extensor mechanism of the finger at mechanism of the finger at

the DIP joint produces the DIP joint produces which of the following which of the following

deformities?deformities?

0%

0%

0%

0%

0% 1.1. Boutonnière deformityBoutonnière deformity

2.2. Mallet fingerMallet finger

3.3. Trigger fingerTrigger finger

4.4. Swan neck deformitySwan neck deformity

5.5. HammertoeHammertoe

Finkelstein’s test is specific Finkelstein’s test is specific for which of the following for which of the following

conditions?conditions?

0%

0%

0%

0%

0% 1.1. Carpal tunnel syndromeCarpal tunnel syndrome

2.2. Bicipital tendonitisBicipital tendonitis

3.3. De Quervain’s tendonitisDe Quervain’s tendonitis

4.4. Trigger fingerTrigger finger

5.5. Tear of the supraspinatus Tear of the supraspinatus tendontendon

Wearing ill-fitting shoes Wearing ill-fitting shoes may produce all of the may produce all of the following deformities following deformities

except _______.except _______.

0%

0%

0%

0% 1.1. Boutonnière deformityBoutonnière deformity

2.2. Hammertoe deformityHammertoe deformity

3.3. Haglund’s deformityHaglund’s deformity

4.4. Hallux valgus deformityHallux valgus deformity

ReferencesReferences Bickley, L.S. & Szilagyi, P.G. (2003). Bickley, L.S. & Szilagyi, P.G. (2003).

Bates’ Guide to Physical Examination Bates’ Guide to Physical Examination and History Takingand History Taking, 8, 8thth Ed., Lippincott, Ed., Lippincott, Williams, & Wilkins. Philadelphia. pp. Williams, & Wilkins. Philadelphia. pp. 465-533465-533

Seidel, H.M. et al. (2003). Seidel, H.M. et al. (2003). Mosby’s Mosby’s Guide to Physical ExaminationGuide to Physical Examination, 5, 5thth Ed., Ed., Mosby. St. Louis. pp. 694-765Mosby. St. Louis. pp. 694-765

DeGowin, R.L. DeGowin, R.L. Diagnostic ExaminationDiagnostic Examination, , 66thth Ed., McGraw-Hill. New York. pp. Ed., McGraw-Hill. New York. pp. 619-753619-753

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