Musculoskeletal Exams and Injections

KneeAnkle

ShoulderWristBack

www.fisiokinesiterapia.biz

Learning Objectives1-Knee exam for effusion and tears of

menisci and ligaments2-Ankle exam to differentiate between

fractures and sprains3-Shoulder exam for impingement syndrome

and tendonitis4-Lower back exam for disc herniation5-Aspirate and inject knee, ankle, foot,

shoulder, wrist and hand

Case #1CC: left knee pain

HPI: 17 yo female adolescent presents to your clinic ~12 hours after twisting her left knee while playing soccer. She reports experiencing a sharp pain to the inner part of her knee immediately following the injury and states she has been unable to completely straighten her left leg.

PE: Moderate joint effusion. Medial joint line tenderness to palpation. Pain with passive flexion and audible click demonstrated upon external rotation of the tibia.

Questions

• What is the most likely diagnosis?• What are some clues from the history that

would lead you to the diagnosis?

Knee Exam• Guided by history

– Mechanism of injury– Location of pain

• Exam– Inspection– Palpation– Maneuvers

• Acute problems– Fractures– Meniscus tear– Ligamentus tear

• Chronic problems– Osteoarthritis– Patellofemoral

arthralgia

Meniscus Injury• History

– Rotational injury– Knee joint locks or gives– Pain is medial or lateral

• Exam– Effusion often present– Tenderness over joint line– McMurray’s test

• flexion/external rotation• flexion/internal rotation• positive w/audible,

palpable pop

McMurray’s Test

(A) Medial Meniscus (Lat. Rotation of Tibia) (B) Lateral Meniscus (Med. Rotation of Tibia)

McMurray Exam

Externally rotate the tibia Extend the knee

University of Washington

Collateral ligaments• History

– Valgus or Varus stress– Pain at/above joint line– Bear some weight

• Exam– Swelling, ecchymosis,

effusion– Tender at/above joint line– Stability testing at 0° & 30°

• *MCL often has meniscus tear

Assessment of collateral ligament stability. The knee should be stressed in full extension and at 30 degrees of flexion. The amount of opening compared with the opposite knee indicates severity of injury.

ACL Maneuvers

• Lachman’s– knee flexed to 30 degrees– femur held in place– tibia brought forward – NO ENDPOINT

• Anterior drawer– knee flexed to 90– proximal tibia held w/both hands, pulled forward– NO ENDPOINT

Anterior Drawer

With the knee flexed to approximately 80° verification ofcomplete relaxation of the hamstrings is achieved by hamstring palpation.

With the foot stabilized and in neutral rotation, a firm, but gentle, grip on the proximal tibia is achieved.

An anterior force is then applied to the proximal tibia with a gentle to-and-fro motion to assess for increased translation compared to the normal contralateral knee.

Lachman’s Test

One hand secures and stabilizes the distal femur while the other firmly grasps the proximal tibia.

A gentle anterior translation force is applied to the proximal tibia.

Demonstrate Knee exam1. Observe standing - valgus, varus, pronation of feet2. Observe Gait3. Sitting - palpate joint margin and lateral collateral ligament4. Lying on back

a. ROMb. Effusion palpable – ballot patella, fluid wavec. Palpate along joint line, tendons, ligaments, bursa

5. Ligamentous stabilitya. Valgus @ 0 and 30 degreesb. Varus @ 0 and 30 degreesc. Lachman test @ 20 0

Anterior drawer @ 90 0d. Posterior drawer

6. Menisci- McMurray test

Case #2CC: left ankle pain

HPI: 34 yo female homemaker presents with pain and swelling to left ankle after accidentally tripping over one of her child’s toys last night. States she been able to walk without assistance but only very slowly.

PE: Swelling and ecchymosis over the lateral malleolus of left ankle. Moderate tenderness to palpation along area just anterior to the malleolus. However, no bony tenderness. Likewise, there is no tenderness to palpation over the navicular nor the base of the 5th metatarsal. Stability assessment reveals a negative anterior drawer.

Questions

• Are radiographic studies indicated for further evaluation?

• Which ligament is most likely involved in this particular case?

The Ankle

• Bones – tibia, fibula,

talus

• Tendons– Achilles' (posterior)– ant tibialis/extensors (anterior)

Lateral Collateral Ligament

Medial – Deltoid Ligament

Ankle Injuries

• History– Inversion– Eversion, forced

plantar/dorsiflexion• Exam

– Inspection• Effusion, edema, ecchymosis

– Palpation• Ligaments• Bony Structures

Grading of Ankle SprainsFirst degree Minimal swellingSecond degree Greater swelling, ecchymosisThird degree Unstable, positive anterior drawer

Ankle Injuries

• 90% rule– 90% sprains– 90% lateral

• ATF, CFL, PTF, Deltoid– Injured in order– Heal in reverse

The Ankle Exam

• Anterior drawer – stabilize tibia– pull foot forward in linear fashion while holding

calcaneus• Talar Tilt

– passive inversion 0° & 30° degrees PF

(A) Method 1- Drawing the foot forward. (B) Method 2- Pushing the leg back.

Anterior Drawer Test

Drawer Test Tilt Test

Ottawa Ankle Rules

• Inability to bear weight

• Point tenderness

BMJ 2003;326:417

Fractures

Demonstrate Ankle exam 1. Can the patient bear weight for 4 steps? Observe.2. Inspection - Swelling, Ecchymosis3. Palpation – Bony

Ligaments - anterior talofibular calcaneofibularposterior talofibulardeltoid

a. Bone tenderness at the posterior edge or tip of either malleolus? b. Bone tenderness at the navicular or the base of the fifth metatarsal?

4. Anterior drawer, Talar tilt

Case #3CC: right shoulder pain

HPI: 51 yo active male presents with aching pain to his right shoulder. Denies any specific injury but mentions he plays tennis at the local country club 5 days/week and has noticed considerable pain when he attempts to serve. Also has symptoms when combing his hair or taking off his shirt.

PE: No swelling or ecchymosis. ROM is full in all planes but discomfort is noted at the end ranges of flexion and abduction. Strength is 4/5 upon resisted abduction vs 5/5 on the left. Pt winces when you place the shoulder in 90 degrees of flexion and then internally rotate. The remainder of the musculoskeletal exam in normal.

Questions

• What is the most likely diagnosis?• What is the most likely muscle involved in

this injury?• What are some predisposing factors for

this type of musculoskeletal problem?

Shoulder Anatomy

• Bony structures– Sternum– Clavicle– Humerus– Scapula

• Glenoid• Acromion

Shoulder: 4 joints

• Sternoclavicular• Acromioclavicular

• Glenohumeral• Scapulothoracic

Anatomy• Muscles

– Rotator cuff • Supraspinatus• Infraspinatus/

teres minor• Subscapularis

– Deltoid– Pectoralis major/minor– Serratus anterior– Latissimus dorsi– Trapezius– Biceps/triceps

Shoulder Exam

• Guided by history– Mechanism of injury– Location of pain

• Exam– Inspection– Palpation– Maneuvers

• Acute problems– Shoulder dislocation– AC separation

• Chronic problems– Shoulder impingement– Bicipital tendonitis

Spurling's Test

Spurling's test for cervical root disorder: The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.

ROM

Painful Arc

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.

AC Separation

• History– Fall on

outstretched hand– Lateral direct

trauma• Exam

– Tender AC joint– Visible gap

Anterior Shoulder Dislocation

• History– Fall– Collision – abducted/

externally rotated– Shoulder popped out

• Exam– Hollow under acromion– Anterior bulge– Check for humeral neck

fracture

Shoulder Impingement

• History– Swimming, throwing– Vague, deep pain– Pain with abduction

above 90• Exam

– Normal appearance– Limited ROM– Scratch test– Empty can test

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.

Neer's Test

Neer's test for impingement of the rotator cuff tendons under the coracoacromial arch: The arm is fully pronated and placed in forced flexion.

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

Bicipital Tendonitis

• History– Overuse– Pain inferior to

acromion• Exam

– Tender at bicipital tendon insertion (Speed’s and Yergason’s test)

Demonstrate Shoulder Exam1) Inspection - symmetry, erythema, swelling2) Bony palpation 3) Soft tissue palpation

rotator cuff - with shoulder extensionbiceps tendon - long head in bicipital groove with

shoulder externally rotated4) ROM

Apley "Scratch" test - Active ROM 5) Muscle strength testing in all 6 cardinal movements of

the shoulder while noting which tests cause patient pain.

Work with 4 joint models

1. Knee: joint, suprapatellar pouch, pes anserine and ITB bursa

2. Ankle and foot: tibiotalar, Morton’s neuroma and plantar fasciitis, 1st MTP

3. Shoulder: subacromial bursa, AC joint, SC joint, biceps tendon

4. Wrist: first metacarpal joint, radioulnar joint, carpal tunnel syndrome, trigger finger, De Quervain’s tenosynovitis

Indications for Diagnostic and Therapeutic Injection

Soft Tissue• Bursitis • Tendonitis or tendinosis • Trigger points • Ganglion cysts • Neuromas • Entrapment syndromes • Fasciitis

Joint • Effusion of unknown

origin or suspected infection (only diagnostic)

• Crystalloid arthropathies • Synovitis • Inflammatory arthritis • Advanced osteoarthritis

Absolute Contraindications• Local cellulitis • Septic arthritis • Acute fracture • Bacteremia • Joint prosthesis • Achilles or patella tendinopathies • History of allergy or anaphylaxis to

injectable pharmaceuticals or constituents

Knee Aspirations and Injections

http://www.aafp.org/afp/20021015/1497.html

Knee Aspirations

Ankle and Foot Injections

Shoulder injections

Posterior Approach

Bicipital Tendon Injection

AC Joint Injection

Hand/Wrist Injections

Carpal Tunnel Syndrome

–Am Fam Physician 2003:68:265-72, 279-80

Method of injecting directly into the carpal tunnel

• hand is positioned on a rolled towel• injected at the distal wrist crease (or 1 cm

proximal to it)• Injection occurs along the ulnar side of the

palmaris longus tendon– have the patient pinch the thumb and fifth fingers

together while slightly flexing the wrist– needle is angled downward at a 45-degree angle

toward the tip of the middle finger and advanced 1 to 2 cm as it traverses the flexor retinaculum.

– Discomfort in the fingers should prompt repositioning of the needle.

– Am Fam Physician 2003:68:265-72, 279-80

Method of injecting proximal to the carpal tunnel

• Using a 3-cm-long, 0.7-mm needle introduced at a 10- to 20-degree angle, a mixture of 10 mg of lidocaine (Xylocaine) and 40 mg of methylprednisolone is injected at the distal wrist crease between the tendons of the palmaris longus and flexor carpi radialis muscles. The mixture is introduced as a bolus and massaged toward the carpal tunnel. The needle should be advanced slowly and repositioned if resistance is encountered or the patient reports pain or paresthesias in the fingers

Am Fam Physician 2003;67:745-50.

Am Fam Physician 2003;67:745-50.

Wrist Joint

De Quervain's Tenosynovitis

Practice with Joint Models

• HAVE FUN!!

Back Anatomy: Muscles

Back Anatomy

Low Back Exam

• History– Mechanism– Red Flags

• Exam– Inspection– ROM– LE neuro exam

• Radiographs?

• Acute problems– Lumbar strain– Disc herniation– Vertebral fracture

• Chronic problems– Osteoarthritis– Spinal stenosis

Acute Low Back Pain• History

– Sudden onset– Less than 4 weeks– Red Flags for:

• Fracture• Infection • Tumor

• Red flags:– Age over 50– Fever– Trauma– Cancer history– Unexplained weight

loss– Drugs (IVDA) – Immunosuppression

Lumbar strain

• History– Pain off midline– Aching, not radicular

• Exam– Muscular tenderness

or spasm– ROM generally intact– Normal neuro exam

Acute Disc Herniation• Exam

– Pain or paresthesias of specific nerve root

– Pain reproduced on straight leg raise

– Corresponding muscle weakness

• L4– Knee jerk absent

• L5– Dorsiflex foot and

great toe– Sensory dorsal foot

• S1– Plantarflex foot– Sensory lateral foot,

posterior calf– Ankle reflex

Because of the way the nerve roots exit, L4-L5 disc pathology usually affects the L5 root

(A) Herniation of the disc between L4 and L5 compresses the fifth lumbar root. (B) Large herniation of the L%-S! disc compromises not only the nerve root crossing it (First sacral) but also Fifth lumbar nerve root. (C) Massive central sequestration, involves all the nerve roots in the cauda equina and may result in bowel and bladder paralysis

Straight Leg Raising (SLR)

Dynamics of SLR

Estimated Accuracy for Lumbar Disc Herniation

90%25%Contralateral SLR

40%80%Ipsilateral SLR

SpecificitySensitivityTest

Vertebral Fracture

• History– Older patients– Risks for osteoporosis– No trauma needed

• Exam– Tenderness over spine– Normal neuro

• Radiographs if suspected

Osteoarthritis

• History– Older patient– Worse with movement– Morning stiffness

• Exam– Decreased ROM– Can have nerve

compression

Demonstrate Back Exam1. Gait - normal, on toes, on heels

toe lifts (on one foot) if suspect Sl radiculopathy2. Range of motion of back while standing3. Palpation of back (sitting) - palpate paraspinal muscles,

vertebrae - spinous process4. Neuro exam - sitting - reflexes, motor, sensory

if absent ankle jerk - retest patient in kneeling position5. Straight Leg Raising (SLR) - supine, ipsilateral and

contralateral6. Abdominal, rectal, pelvic exams - as needed

References• Physical Examination of the Spine and Extremities.

Stanley Hoppenfeld • Orthopedic Physical Assessment, David J. Magee• The CIBA collection of Medical Illustrations, MS system,

Frank H. Netter• The Painful Shoulder: Part I. Clinical Evaluation. Thomas

W. Woodward, Thomas M. Best• The Injured Ankle. Randell K. Wexler• Acute Knee Injuries. Howard B. Tandeter, Pesach

Shvartzman, Max A. Stevens