Taming the Musculoskeletal Exam:

İSí, se puede!Ronald H. Labuguen, MD

UCSF Department of Family and Community Medicine

NP/PA/CNM Professional Practice ConferenceSan Francisco Department of Public Health

October 17, 2013

Objectives

1. To learn principles of examining patients with common joint problems

2. To learn common clinical scenarios for common musculoskeletal problems

3. To learn how to approach diagnosis and treatment of common musculoskeletal problems in primary care and urgent care settings

Objectives

4. To review elements of the physical examination of the shoulder, elbow, hand/wrist, hip, knee, ankle, and foot

5. To develop a systematic physical examination of the shoulder and knee

Principles: Approaching Joint Problems

• Learn typical clinical scenarios for common joint problems:– History– Chief complaints– Timing/duration of symptoms– Typical findings

Principles: Approaching Joint Problems

• Know functional anatomy, physical examination techniques for each joint

• Initial and subsequent treatment

• Red flags: need for referral or immediate treatment

Common Joints

• Upper extremity:– Hand/wrist– Elbow– Shoulder

• Lower extremity:– Hip– Knee– Ankle– Foot

Case 1: Hand/Wrist

• 43 yo man c/o hand numbness

Carpal Tunnel Syndrome

• Compression of the median nerve through the carpal tunnel

• Inflammatory• Overuse• Paresthesias• Worse at night,

upon awakening

Carpal Tunnel Syndrome

• Neuro exam: sensation, strength

• Know median nerve distribution and innervation

• Thenar atrophy

Carpal Tunnel Syndrome

• Tinel’s sign• Phalen’s sign• Flick sign

Carpal Tunnel Syndrome

• NSAID’s• Volar (cock-up)

wrist splint• Steroid injection• Surgery

Other Common Hand and Wrist Problems

• Arthritis• De Quervain tenosynovitis• Fall on outstretched hand (FOOSH)• Fractures: phalanges, metacarpals,

scaphoid (navicular), distal radius• Ganglion cyst• Trigger finger• Mallet finger

http://en.wikipedia.org/wiki/File:Mallet_finger.jpg

Case 2: Elbow

• 43 yo man c/o pain in elbow

Lateral Epicondylitis

• Tears/microtears in tendons originating at lateral epicondyle

• Overuse of forearm muscles

• Inflammatory• Constant symptoms

– Aching night pain referring to humerus

Lateral Epicondylitis

• Pain on palpation just distal to lateral epicondyle

• Pain with resisted– Active extension

(passive flexion) of wrist

– Supination– 3rd finger extension

Lateral Epicondylitis

• NSAIDs• Tennis elbow

brace• Steroid

injection• Surgery

Other Common Elbow Problems

• Arthritis• Fractures: distal humerus,

radial head• Medial epicondylitis• Olecranon bursitis• Nerve compression syndromes• Rupture of distal biceps tendon

Radial Head Fracture

• Most common fracture in adults

• FOOSH, axial load to distal radius

• TTP @ radial head• Ballotable hemarthrosis

Lateralepicondyle

Radialhead

Case 3: Shoulder

• 43 yo man c/o right shoulder pain

Impingement Syndrome

• Inflammation of subacromial bursa and rotator cuff tendons

• Overuse• Continuum of

pathology

Impingement Syndrome

• Anterior and lateral shoulder pain

• Gradual onset• Overhead

activity• Worse at night• Can’t sleep on

affected side

Impingement Syndrome

• Palpation– Greater

tuberosity– Subacromial

bursa• Signs:

– Neer– Hawkins– Supraspinatus

impingement

Impingement Syndrome

• NSAIDs• Rest• Stretching &

strengthening• Steroid

injection• Surgery

Other Common Shoulder Problems

• Acromioclavicular arthritis/injury• Arthritis• Fractures of the clavicle, humerus,

scapula• Rotator cuff tear• Biceps tendon rupture• Shoulder instability• Superior Labrum Anterior-to-Posterior

(SLAP) lesions• Thoracic outlet syndrome

http://en.wikipedia.org/wiki/File:Luxation_epaule.PNG

Shoulder Exam

• Inspection• Range of Motion• Palpation

Shoulder Exam

• Special tests– Impingement signs: Neer,

Hawkins– Strength testing: Supraspinatus,

external/internal rotation– O’Brien’s test (SLAP lesion)– Apprehension sign

(glenohumeral instability)

Case 4: Hip

• 63 yo man c/o thigh pain

Osteoarthritis of the Hip

• Degenerative• Loss of articular

cartilage• Primary or

secondary• Trauma• Osteonecrosis• Previous joint

infections

Osteoarthritis of the Hip• Gradual onset of anterior

thigh or groin pain• Buttock or lateral thigh

pain• Referred pain to distal

thigh, knee• Initially only with

activity; more constant later

• Decreased ROM• Limp, stiffness

Osteoarthritis of the Hip

• ROM: loss of internal rotation first

• Fixed external rotation and flexion contracture

• Antalgic gait• Abductor lurch

Osteoarthritis of the Hip

• X-rays:– Joint space

narrowing– Osteophytes– Subchondral

cysts– Subchondral

sclerosis

Osteoarthritis of the Hip• Pain/anti-

inflammatory medication

• Activity modification

• Assistive device• NWB exercise• Steroid injections• Surgery

Other Common Hip Problems

• Osteonecrosis of the hip• Snapping hip• Hip strains• Trochanteric bursitis• Fractures: pelvis, proximal

femur

Case 5: Knee

• 34 yo woman c/o knee pain

Management of Patellofemoral Pain SyndromeSAMEER DIXIT, M.D., AND JOHN P. DIFIORI, M.D., UNIVERSITY OF CALIFORNIA, LOS ANGELES, LOS ANGELES, CALIFORNIAMONIQUE BURTON, M.D., UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTONBRANDON MINES, M.D., EMORY UNIVERSITY, ATLANTA, GEORGIA Am Fam Physician 2007;75:194-202, 204. Copyright © 2007 American Academy of Family Physicians

Patellofemoral Pain

• Overuse/ overloading

• Diffuse, aching anterior knee pain

• Sometimes caused by patellar malalignment

Patellofemoral Pain

• Feels like knee “catches” or might “give way”

• Worst when– Running– Going up/down

stairs– Kneeling,

squatting– Getting up after

sitting for a while

Patellofemoral Pain

• Weight bearing stance and gait:– Patellae point

to each other– Knock-knees– Foot pronation

Patellofemoral Pain• Excessive femoral

anteversion (hip internal rotation > external rotation by 30°+)

• J sign (patella moves laterally >1 cm near full extension)

• Tight hamstrings, quadriceps

• Patellar grind test• Patellar apprehension test

Lateral patellar tracking("J" sign).

As the knee is extended from 90 degrees flexion (A) to full extension (B), the patella demonstrates an abnormal path, deviating laterally at full extension.

Patellar mobility testing.

Depicted is medial glide testing performed on the right knee.

The patella is grasped in the resting position (A), then translated medially (B).

The extent of displacement is described in relation to the width of the patella and measured in quadrants (C).

Displacement of less than one quadrant medially indicates tightness of the lateral structures. Displacement of more than three quadrants is considered hypermobile.

Patellar tilt test.This test assesses for tightness of the lateral structures.

The knee is extended and the patella is grasped between the thumb and forefinger. The medial aspect of the patella is then compressed posteriorly while the lateral aspect is elevated.

If the lateral aspect of the patella is fixed and cannot be raised to at least the horizontal position (0 degrees), the test is positive and indicates tight lateral structures.

This also can be seen in patients with patellofemoral osteoarthritis.

Patellar grind (or inhibition) test.While the patient is in the supine position with the knee extended, the examiner displaces the patella inferiorly into the trochlear groove (pictured). The patient is then asked to contract the quadriceps while the examiner continues to palpate the patella and provides gentle resistance to superior movement of the patella.The test is positive if pain is produced, although comparison to the contralateral knee is needed to interpret the result.

Patellofemoral Pain• X-rays

– Rule out malalignment, arthritis

Patellofemoral Pain

• Relative rest• Quadriceps

strengthening• Increase flexibility

in quadriceps and hamstrings

• Brace• Analgesics• Surgery

“The knee is the worst-designed joint in the human

body.”

Other Common Knee Problems

• Ligament injuries: ACL, MCL, LCL, PCL

• Arthritis• Bursitis (prepatellar, pes anserine)• Iliotibial band syndrome• Meniscal tear• Patellar/quadriceps tendinitis• Popliteal (Baker’s) cyst

Knee Exam

• Inspection• Palpation• Special tests

– Ligament– Meniscus

Knee Exam

• ACL – Lachman’s• PCL – Posterior drawer, sag sign• MCL – valgus stress• LCL – varus stress• Meniscus – McMurray’s

circumduction, Apley’s grind, Thessaly

Knee X-ray Tips

• Ottawa Ankle Rules– Age ≥ 55– Unable to bear weight 4 steps– Unable to flex to 90°– Isolated tenderness of patella– Tenderness at fibular head

• Weight bearing films for dx of OA

RAZIB KHAUND, M.D., SHARON H. FLYNN, M.D., Iliotibial Band Syndrome: A

Common Source of Knee Pain Am Fam Physician 2005;71:1545-50

Ober's test.The patient lies down with the unaffected side down and the unaffected hip and knee at a 90-degree angle.If the iliotibial band is tight, the patient will have difficulty adducting the leg beyond the midline and may experience pain at the lateral knee (arrows).

Case 6: Ankle

• 43 yo man c/o acute ankle injury and pain

Ankle Sprain• Inversion injury• Stretching or

tearing of lateral ligaments

Ankle Sprain

• Watch out!– Fractures (e.g.,

avulsion fracture at base of 5th metatarsal)

– Distal or proximal fibula fracture

– Peroneal tendon tear or subluxation

– Lisfranc injury

Ottawa Ankle Rules

Ankle Sprain

• NSAIDs, RICE• ?Ambulatory cast• WBAT• Early mobilization• Rehab:

– Strengthening– Proprioception– Agility– Endurance

training

Other Common Ankle Problems

• Achilles tendonitis or rupture• Chronic lateral ankle pain• Fractures

Case 7: Foot

• 43 yo man c/o chronic heel pain

Plantar Fasciitis

• Microtrauma of the plantar fascia at the insertion in the medial tuberosity of the calcaneus

• Overuse• Inflammatory• More common in

women, overweight

Plantar Fasciitis

• Insidious onset• Worst when

arising from resting position, prolonged standing/walking

Plantar Fasciitis

• Focal pain and tenderness over medial calcaneal tuberosity and 1-2 cm distally along plantar fascia

• Pain with passive dorsiflexion of toes

• Achilles tendon tightness

Plantar Fasciitis• Stretching• Anti-

inflammatory treatments

• Orthotics (heel pad)

Plantar Fasciitis

• Tension night splint

Plantar Fasciitis

• Steroid injection• Surgery

Other Common Foot Problems

• Bunion• Fractures• Interdigital (Morton) neuroma• Metatarsalgia• Posterior heel pain• Tarsal tunnel syndrome• Turf toe (1st MT joint sprain)

Summary: See? İse puede!

• Joint complaints are commonly seen in family medicine

• Learn the functional anatomy of the joints and how it relates to the physical exam

• Learn typical historical scenarios for common joint problems and the workup associated with each

References

• Greene WB, ed. Essentials of Musculoskeletal Care, 3rd ed. Rosemont (Ill.): American Academy of Orthopaedic Surgeons, 2005.

• American Family Physician, various articles.

• Joseph Moore, MD, Elbow, Wrist and Hand Injuries, AAFP 2013 Ann. Sci. Assembly.