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Adv Musc Exam Portfolio 09


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Adv Musc Exam Portfolio 09

  1. 1. Advanced Musculoskeletal Examination Physical Diagnosis III Steven Sager, MPAS, PA-C
  2. 2. Learning Objectives <ul><li>Upon satisfactory completion of this lecture, and in conjunction with textbooks, lecture handouts, WebCT, and recommended internet web sites, the student will be able to: </li></ul><ul><ul><li>Review the articular anatomy of the musculoskeletal system </li></ul></ul><ul><ul><li>List the patient history information that will aid in developing a diagnosis for joint disorders </li></ul></ul><ul><ul><li>Review techniques for the standard examination of the diarthroses </li></ul></ul><ul><ul><li>Identify special techniques of examination of the diarthroses </li></ul></ul><ul><ul><li>Compare and contrast the techniques for evaluating: </li></ul></ul><ul><ul><ul><li>Fractures, sprains, strains and dislocations </li></ul></ul></ul><ul><ul><ul><li>Osteoarthritis and rheumatoid arthritis </li></ul></ul></ul><ul><ul><ul><li>Tendonitis </li></ul></ul></ul><ul><ul><li>Perform a thorough examination of the musculoskeletal system using standard and special techniques, as appropriate </li></ul></ul>
  3. 3. Shoulder pain <ul><li>Right side: </li></ul><ul><ul><li>Gallbladder disease </li></ul></ul><ul><ul><li>Peptic ulcer </li></ul></ul><ul><ul><li>Liver abscess/tumor </li></ul></ul><ul><li>Left side: </li></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Splenic rupture </li></ul></ul><ul><li>Always consider non-orthopedic etiologies: </li></ul><ul><ul><li>Pericarditis – “sharp” chest pain, fever, tachycardia/tachypnea </li></ul></ul><ul><ul><li>Myocardial ischemia – HTN, tachycardia, SOB, syncope </li></ul></ul><ul><ul><li>Pulmonary disease – cough, fever, tachypnea </li></ul></ul>
  4. 4. HPI <ul><li>Patient’s age </li></ul><ul><li>Dominant hand </li></ul><ul><li>Trauma </li></ul><ul><li>Occupation </li></ul><ul><li>Sports </li></ul><ul><li>Hobbies </li></ul><ul><li>ADLs </li></ul><ul><li>Dysesthesia </li></ul>
  5. 5. Physical Examination - Shoulder <ul><li>Pertinent positives and negatives for shoulder exam: </li></ul><ul><ul><li>edema, erythema, ecchymosis, effusion </li></ul></ul><ul><ul><li>stiffness, “clicking” </li></ul></ul><ul><ul><li>instability </li></ul></ul><ul><ul><li>deformity </li></ul></ul><ul><ul><ul><li>winging </li></ul></ul></ul><ul><ul><li>tenderness (where?) </li></ul></ul><ul><ul><ul><li>bursitis (inflammatory, septic, DJD) </li></ul></ul></ul><ul><ul><ul><li>rhomboid vs. trapezius spasm </li></ul></ul></ul><ul><ul><ul><li>shoulder girdle, axilla, and clavicle status </li></ul></ul></ul><ul><ul><ul><li>? AC separation </li></ul></ul></ul><ul><ul><ul><li>? shoulder dislocation </li></ul></ul></ul>
  6. 6. ROM and muscle strength (active/passive) <ul><li>Active movement through the arc </li></ul><ul><li>“ clicking” = tear of the glenoid labrum or glenohumeral capsule </li></ul><ul><li>Instability = rotator cuff tear </li></ul><ul><li>Limitations: </li></ul><ul><ul><li>active & passive = adhesive capsilitis & fracture </li></ul></ul><ul><ul><li>active only = rotator cuff tear </li></ul></ul>
  7. 7. Case Study <ul><li>14y.o. female c/o “deformed” right shoulder. Denies trauma. Parents noted protuberant back bones at age 4 during gymnastics. Denies upper extremity weakness </li></ul><ul><li>Dx? </li></ul>
  8. 8. Specialty testing of the Shoulder <ul><li>Apley scratch test </li></ul><ul><li>Apprehension test </li></ul><ul><li>Sulcus test </li></ul><ul><li>Yeargersons test </li></ul><ul><li>Rotator cuff impingement test </li></ul><ul><ul><li>flexion-internal rotation test </li></ul></ul><ul><li>Drop arm test </li></ul><ul><li>Supraspinatus strength test </li></ul><ul><ul><li>“ empty can test” </li></ul></ul><ul><li>Cross chest test </li></ul><ul><ul><li>horizontal adduction test </li></ul></ul><ul><li>Speed’s test </li></ul><ul><li>Dugas’ test </li></ul>
  9. 9. Apley Scratch Test <ul><li>Abduction and External Rotation </li></ul><ul><ul><li>ask the patient to reach behind his or her head and touch the superior medial angle of the opposite scapula. </li></ul></ul><ul><li>Adduction and Internal Rotation </li></ul><ul><ul><li>instruct the patient to reach back and touch the inferior angle of the opposite scapula . </li></ul></ul><ul><ul><li>you may also assess adduction and internal rotation by having the patient reach in front and touch the opposite acromion process. </li></ul></ul><ul><li>Document the level of thoracic vertebrae reached. * </li></ul>
  10. 10. Apprehension Test <ul><li>Position the patient supine in a relaxed position on the examination table. </li></ul><ul><li>Support the patient's arm with the shoulder abducted 90 degrees and the elbow flexed 90 degrees. </li></ul><ul><li>While supporting the humerus at the elbow with one hand, grasp the patient's forearm with your other hand. </li></ul><ul><li>Gently and gradually externally rotate the shoulder. </li></ul><ul><ul><li>if the patient has had a recent anterior dislocation or subluxation of the glenohumeral joint, apprehension or discomfort will occur as the shoulder approaches 90 degrees of external rotation. </li></ul></ul><ul><li>Be careful not to cause an actual anterior dislocation when externally rotating the arm. * </li></ul>
  11. 11. Sulcus Test <ul><li>Have the patient stand with the involved arm hanging relaxed at the side. </li></ul><ul><li>Ask the patient to use the unaffected hand to grasp the wrist of the involved arm. </li></ul><ul><li>Apply a downward directed, distractive force on the involved arm and palpate the space between the humeral head and the undersurface of the acromion. </li></ul><ul><ul><li>note any indentions (sulcus) on the top of the mid-deltoid as the humeral head subluxes inferiorly. </li></ul></ul><ul><li>You should also perform this test on the uninvolved shoulder, comparing bilaterally. * </li></ul>
  12. 12. Examination of the Rotator Cuff <ul><li>“ SITS” muscles </li></ul><ul><ul><li>passively extend the shoulder </li></ul></ul><ul><ul><ul><li>palpate over the greater tuberosity of the humerus </li></ul></ul></ul><ul><ul><li>abduct against resistance </li></ul></ul><ul><ul><ul><li>“ drop arm” sign </li></ul></ul></ul><ul><ul><li>adduct against resistance </li></ul></ul><ul><ul><li>internally rotate against resistance </li></ul></ul><ul><ul><li>externally rotate against resistance </li></ul></ul>
  13. 13. Rotator Cuff Impingement Test (flexion-internal rotation test) <ul><li>Stand to the side of the patient's involved shoulder and grasp the patient's elbow with one hand and support the arm so that both the elbow and shoulder are flexed 90 degrees. </li></ul><ul><li>Place your other hand on the patient's forearm and maximally, internally rotate the humerus. </li></ul><ul><ul><li>this passive movement drives the greater tuberosity under the coracoacromial arch and impinges the rotator cuff. </li></ul></ul><ul><li>This movement will elicit a painful response if rotator cuff inflammation or impingement syndrome is present. </li></ul><ul><li>You should also perform this test on the uninvolved shoulder and compare bilaterally. * </li></ul>
  14. 14. Drop Arm Test (Supraspinatus Test) <ul><li>Place the arm to be tested at 90 degrees abduction </li></ul><ul><ul><li>internally rotate the arm </li></ul></ul><ul><ul><li>try to slowly lower the arm to the side </li></ul></ul><ul><li>Have the patient maintain this arm position as you tap down on the forearm. </li></ul><ul><ul><li>if there is a tear of the supraspinatus tendon, the arm will drop because of weakness or pain. </li></ul></ul><ul><li>Codman’s test/sign </li></ul>
  15. 15. Supraspinatus Strength Test (The Empty Can Test) <ul><li>The patient stands with both arms in 90 degrees of abduction, 30 degrees of horizontal adduction and full internal rotation </li></ul><ul><li>Ask the patient to maintain this position. </li></ul><ul><li>Place your hands on the superior aspect of the elbow and press downward. </li></ul><ul><li>Compare the patient's ability to resist your downward pressure with both the involved and uninvolved shoulders. </li></ul><ul><ul><li>decreased ability of the involved shoulder to resist your downward pressure as compared to the uninvolved shoulder is indicative of supraspinatus weakness. </li></ul></ul><ul><li>This test may also elicit pain, indicating inflammation and muscle weakness. * </li></ul>
  16. 16. Cross Chest Or Horizontal Adduction Test <ul><li>Assesses acromioclavicular joint impingement </li></ul><ul><li>With the patient supine or standing, grasp the distal humerus with one hand and position it in 90 degrees of abduction. </li></ul><ul><li>Passively move the humerus across the chest. </li></ul><ul><li>As the humerus approaches full horizontal adduction, question the patient regarding pain in the acromioclavicular joint. </li></ul><ul><li>Lightly place the fingers of your other hand over the acromioclavicular joint to palpate for crepitus and separation. </li></ul><ul><ul><li>this procedure compresses (impinges) the acromioclavicular joint and is painful if internal derangement or instability exist. </li></ul></ul><ul><li>Perform this test on the uninvolved shoulder and compare bilaterally. * </li></ul>
  17. 17. Speed’s Test <ul><li>Used to assess the integrity of the biceps tendon. </li></ul><ul><li>Arm is extended behind and the forearm supinated with elbow slightly flexed. </li></ul><ul><li>Examiner resists shoulder forward flexion by the patient while the patient’s arm is supinated and the elbow is completely extended. </li></ul><ul><li>Positive test elicits increased tenderness in the bicipital groove and indicates bicipital tendonitis. </li></ul>
  18. 18. Adson Maneuver <ul><li>Test for Thoracic Outlet Syndrome </li></ul><ul><li>Patient’s head is rotated to face the tested shoulder. </li></ul><ul><li>Patient then extends the head while the examiner laterally rotates and extends the patient’s shoulder. </li></ul><ul><li>Examiner locates radial pulse and the patient is instructed to take a deep breath and hold it. </li></ul><ul><li>Disappearance of pulse is indicative of a positive test. </li></ul>
  19. 21. Clinical Findings <ul><li>Dislocation </li></ul><ul><li>Rotator Cuff Tear </li></ul><ul><ul><li>common cause of pain and weakness in the shoulder </li></ul></ul><ul><ul><li>frequent use of the hands in the overhead position causes inflammation, pain, and tenderness in the tendons and ligaments eventually weakening the rotator cuff resulting in tears of the tendons. </li></ul></ul><ul><ul><li>traumatic tear = a direct blow to the shoulder, a fall onto an outstretched hand, or a dislocated shoulder joint results in a tear of one of the rotator cuff tendons. </li></ul></ul><ul><ul><li>degenerative tear = a process of natural wear and tear breaks down the strength and flexibility of the rotator cuff tendons, leading to a complete rupture of one of the tendons. </li></ul></ul><ul><li>Backpack palsy </li></ul><ul><ul><li>Brachial plexus overpull caused by a heavy backpack’s shoulder straps resulting in palsy along the 5 th and 6 th cervical nerve distribution </li></ul></ul>
  20. 22. Which of the following tests/signs is not specific for a tear of the rotator cuff? <ul><li>Speeds test </li></ul><ul><li>Codman signs </li></ul><ul><li>Empty can test </li></ul><ul><li>Sulcus sign </li></ul><ul><li>Drop arm test </li></ul>
  21. 23. Physical Examination – Upper Extremity <ul><li>Pertinent positives and negatives for elbow/hand exam: </li></ul><ul><ul><li>edema, erythema, ecchymosis, effusion </li></ul></ul><ul><ul><li>deformity </li></ul></ul><ul><ul><li>crepitus </li></ul></ul><ul><ul><li>tenderness: (where?) </li></ul></ul><ul><ul><ul><li>bursitis (inflammatory, septic) </li></ul></ul></ul><ul><ul><ul><li>snuff box </li></ul></ul></ul><ul><ul><ul><li>tendonitis/tenosynovitis (inflammatory, infectious) </li></ul></ul></ul><ul><ul><ul><li>sprain, strain, fracture </li></ul></ul></ul><ul><ul><ul><ul><li>Fx (volar plate, boxer's, Bennett's, Colle's, nightstick) </li></ul></ul></ul></ul><ul><ul><ul><li>overuse syndrome </li></ul></ul></ul><ul><ul><ul><li>ROM (active/passive) </li></ul></ul></ul><ul><ul><ul><li>muscle strength (active/passive) </li></ul></ul></ul><ul><ul><li>flexor and extensor tendon integrity </li></ul></ul><ul><ul><li>nodules/cysts </li></ul></ul>
  22. 24. Clinical Findings <ul><li>Olecranon bursitis </li></ul><ul><ul><li>localized edema over the olecranon process </li></ul></ul><ul><li>Lateral Humeral epicondylitis </li></ul><ul><ul><li>tenderness over the lateral epicondyle </li></ul></ul><ul><li>Radial head fracture </li></ul><ul><ul><li>tenderness in lateral antecubital fossa </li></ul></ul><ul><ul><li>tenderness distal to the lateral humeral epicondyle </li></ul></ul><ul><li>Nursemaid’s elbow </li></ul><ul><ul><li>traction injury to a child’s forearm resulting in anterior and superior dislocation of the radial head </li></ul></ul>
  23. 25. Tennis Elbow Test <ul><li>Stabilize the forearm </li></ul><ul><li>Instruct the patient to make a fist and extend the wrist </li></ul><ul><li>Examiner provides resistance </li></ul><ul><li>Positive if sudden, sharp pain at epicondyle </li></ul>
  24. 26. Clinical findings
  25. 27. Clinical findings
  26. 28. Special Testing of the Wrist and Hand <ul><li>Scaphoid Compression Test </li></ul><ul><li>Finkelstein's Test </li></ul><ul><li>Phalen’s Test </li></ul><ul><li>Tinel's Test </li></ul><ul><li>Allen test </li></ul>
  27. 29. Scaphoid Compression Test <ul><li>The patient should rest the involved forearm on the table. </li></ul><ul><li>Ask the patient to extend the thumb so that these tendons become prominent. </li></ul><ul><ul><li>the anatomical snuff box is formed by space between the abductor pollicis longus and extensor pollicis brevis tendons on the radial border and the extensor pollicis longus tendon on the ulna side. </li></ul></ul><ul><li>The examiner presses in the anatomical snuffbox, applying compression to the scaphoid navicular bone. </li></ul><ul><li>Pain with palpation of the snuffbox is indicative of a scaphoid fracture, particularly if the patient also has pain in the same area with passive wrist hyperextension. </li></ul>
  28. 31. Finkelstein's Test <ul><li>Determines presence of De Quervain's tenosynovitis or Hoffman's disease in the abductor pollicis longus and the extensor pollicis brevis tendons of the thumb. </li></ul><ul><li>Technique: </li></ul><ul><ul><li>patient sits with the forearm supported on the table in a neutral position. </li></ul></ul><ul><ul><li>the hand should be free to hang over the table edge. </li></ul></ul><ul><ul><li>instruct the patient to make a fist with the thumb inside the fingers, deviating the wrist to the ulnar side. </li></ul></ul><ul><ul><li>the examiner can accentuate the test by using one hand to stabilize the distal forearm while placing your other hand over the fist's radial side to push the wrist into further ulnar deviation. * </li></ul></ul>
  29. 32. Phalen’s Test <ul><li>Detects Carpal Tunnel Syndrome </li></ul><ul><li>Technique: </li></ul><ul><ul><li>instruct the patient to flex both shoulders and elbows approximately 90 degrees. </li></ul></ul><ul><ul><li>then ask the patient to flex both wrists so that the dorsal surface of both hands can be placed against one another. </li></ul></ul><ul><ul><li>hold this maximally flexed position for at least one minute </li></ul></ul><ul><li>After approximately one minute, tingling or numbness in the median nerve distribution over the involved palmar surface indicates the presence of carpal tunnel syndrome. </li></ul>
  30. 33. Tinel's Sign <ul><li>Detects Carpal Tunnel Syndrome </li></ul><ul><li>Technique: </li></ul><ul><ul><li>position the patient with the forearm in supination and the hand relaxed on the table surface </li></ul></ul><ul><ul><li>use your index finger to tap over the carpal tunnel at the wrist </li></ul></ul><ul><li>A positive test results when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the middle finger and lateral half of the ring finger. </li></ul>
  31. 34. Clinical Findings <ul><li>Boutonnière’s deformity </li></ul><ul><ul><li>tear injury to the extensor mechanism of the finger resulting in a fixed deformity that consists of flexion of the PIP joint and extension of the DIP joint </li></ul></ul><ul><li>Mallet finger </li></ul><ul><ul><li>injury to the extensor mechanism of the finger at the DIP joint </li></ul></ul><ul><li>Swan-neck deformity </li></ul><ul><ul><li>hyperextension injury to the PIP joint of the finger resulting in hyperextension of the PIP joint and flexion of the DIP joint </li></ul></ul><ul><li>Trigger finger </li></ul><ul><ul><li>inflammation of the flexor tendon and synovial sheath causing the finger to “catch” as it extends </li></ul></ul>
  32. 35. Clinical Findings <ul><li>Gamekeeper’s thumb </li></ul><ul><ul><li>partial subluxation and instability of the thumb at the MCP joint caused by rupture of the ulnar collateral ligament </li></ul></ul><ul><li>Jersey finger </li></ul><ul><ul><li>avulsion of the flexor tendon of the 4 th or 5 th finger </li></ul></ul>
  33. 36. Case Study <ul><li>48-year-old female complains of finger and knuckle pain in the MCP and PIP of the index and middle fingers in her right hand x1 year. She is RHD. Recent exacerbation. AM stiffness and stuck in flexion at the PIP joint. Decreased grip. No trauma. No dysesthesias. </li></ul><ul><li>PMH: uncontrolled NIDDM, arthritis and adhesive capsilitis in R shoulder </li></ul>
  34. 37. Case Study <ul><li>VSS </li></ul><ul><li>1+ edema over MCP joints of right index and middle fingers </li></ul><ul><li>Motor and sensory are intact </li></ul><ul><li>Additional tests? </li></ul><ul><li>Dx? </li></ul><ul><li>Tx? </li></ul>
  35. 38. Physical Examination - Knee <ul><li>Pertinent positives and negatives for knee exam: </li></ul><ul><ul><li>edema, erythema, ecchymosis, effusion </li></ul></ul><ul><ul><li>deformity/malalignment </li></ul></ul><ul><ul><li>stability </li></ul></ul><ul><ul><ul><li>valgus (med collateral) </li></ul></ul></ul><ul><ul><ul><li>varus (lat collateral) </li></ul></ul></ul><ul><ul><ul><li>anterior drawer (anterior cruciate) </li></ul></ul></ul><ul><ul><ul><li>posterior drawer (posterior cruciate) </li></ul></ul></ul><ul><ul><ul><li>Lachman's (ACL) </li></ul></ul></ul><ul><ul><ul><li>posterior sag (PCL) </li></ul></ul></ul><ul><ul><li>masses </li></ul></ul><ul><ul><li>tenderness </li></ul></ul><ul><ul><ul><li>patellar grind (PFS, CMP) </li></ul></ul></ul>
  36. 39. Physical Examination - Knee <ul><li>Pertinent positives and negatives for knee exam: </li></ul><ul><ul><li>ballotment, bulge sign (effusion) </li></ul></ul><ul><ul><li>McMurray's (meniscus) </li></ul></ul><ul><ul><li>Apley's compression (meniscus) </li></ul></ul><ul><ul><li>Apley's distraction (collaterals) </li></ul></ul><ul><ul><li>Tinel sign (neuromata) </li></ul></ul><ul><ul><li>ROM (active/passive) </li></ul></ul><ul><ul><li>muscle strength (active/passive) </li></ul></ul><ul><ul><li>neurovascular check (L4, L5, S1) - sensory specific </li></ul></ul>
  37. 40. Clinical Findings <ul><li>Genu valgum </li></ul><ul><ul><li>malalignment of the knees medially; “knock-kneed” </li></ul></ul><ul><li>Genu varum </li></ul><ul><ul><li>malalignment of the knees laterally; “bow-legged” </li></ul></ul><ul><li>Housemaid’s knee </li></ul><ul><ul><li>prepatellar bursitis caused by prolonged kneeling </li></ul></ul>
  38. 41. Clinical findings
  39. 42. Special testing of The Knee <ul><li>patellar movement </li></ul><ul><li>patellar compression test </li></ul><ul><li>palpate the prepatellar bursa </li></ul><ul><li>valgus stress </li></ul><ul><li>varus stress </li></ul><ul><li>ballottement </li></ul><ul><li>drawer sign (anterior & posterior) </li></ul><ul><li>Lachman test </li></ul><ul><li>McMurray test </li></ul><ul><li>Apley’s test </li></ul>
  40. 43. Ballottement <ul><li>Used to assess for fluid/effusion in the knee </li></ul><ul><li>Technique: </li></ul><ul><ul><li>knee extended </li></ul></ul><ul><ul><li>apply downward pressure on the suprapatellar pouch </li></ul></ul><ul><ul><li>push the patella sharply downward </li></ul></ul><ul><li>If an effusion is present: </li></ul><ul><ul><li>tapping or clicking will be felt when the patella strikes the femur </li></ul></ul><ul><ul><li>the patella will “float” outward when pressure is released </li></ul></ul>
  41. 44. Drawer Test <ul><li>Used to assess anterior and posterior cruciate ligament injury </li></ul><ul><li>Technique: </li></ul><ul><ul><li>position the patient with the knee flexed 90 degrees, the lower leg in neutral rotation, and the hip flexed to 45 degrees </li></ul></ul><ul><ul><li>the examiner medially rotates the patients foot slightly and sits on the foot to stabilize it </li></ul></ul><ul><ul><li>examiner pushes and pulls on the tibia </li></ul></ul><ul><li>The test is positive if tibia moves or rotates an excessive amount compared to the normal knee. </li></ul>
  42. 45. Lachman’s Test <ul><li>Used to evaluate the anterior cruciate ligament (ACL) </li></ul><ul><li>Technique: </li></ul><ul><ul><li>patient supine </li></ul></ul><ul><ul><li>flex knee 0-30°, keep heel on the table </li></ul></ul><ul><ul><li>stabilize the femur just above the knee </li></ul></ul><ul><ul><li>pull the proximal tibia anteriorly </li></ul></ul><ul><li>Increased laxity (>5 mm) indicates ACL injury </li></ul>
  43. 46. McMurray’s Test <ul><li>Place the knee in full flexion. </li></ul><ul><li>The foot is held in one hand while the other hand palpates the joint line on both sides of the knee. </li></ul><ul><li>A click or grinding may indicate a tear of the posterior segment of the meniscus while flexing and extending the knee. * </li></ul>
  44. 47. Apley’s Test <ul><li>Used to assess the knee for: </li></ul><ul><ul><li>medial or lateral menisci injury </li></ul></ul><ul><ul><li>internal derangement </li></ul></ul><ul><ul><ul><li>osteochondritis dissecans </li></ul></ul></ul><ul><ul><ul><li>osteochondral fractures. </li></ul></ul></ul><ul><li>Technique: </li></ul><ul><ul><li>patient prone with knee in 90° flexion </li></ul></ul><ul><ul><li>pressure is then applied to the heel while the foot is rotated </li></ul></ul><ul><ul><li>* </li></ul></ul>
  45. 48. Case Study <ul><li>17y.o. female presents with localized, constant “sharp” left knee pain (8/10) since last night. Acute onset with ? instability secondary to a “stop and twist” injury while playing flag football. No audible pop. Immediate edema which has worsened. Tx with ice at scene. Increased pain with ambulation. No relief with OTC meds. NWB with crutches. </li></ul>
  46. 49. Case Study (cont.) <ul><li>Physical examination reveals 3+ periarticular edema in the left knee. AROM is limited to 70° flexion and -10° extension. No laxity on varus/valgus stress. Unable to perform other tests due to pain. </li></ul><ul><li>Which of the following knee tests would you expect to be positive? </li></ul><ul><ul><li>Lachman </li></ul></ul><ul><ul><li>McMurray </li></ul></ul><ul><ul><li>Drawer test </li></ul></ul><ul><ul><li>Apley’s </li></ul></ul><ul><ul><li>None of the above </li></ul></ul><ul><li>What’s next? </li></ul>
  47. 53. Case Study (cont.) <ul><li>Key points: </li></ul><ul><ul><li>mechanism of injury </li></ul></ul><ul><ul><li>absence of “pop” </li></ul></ul><ul><ul><li>acute swelling </li></ul></ul><ul><ul><li>inability to bear weight </li></ul></ul>
  48. 54. Clinical findings
  49. 55. Clinical findings
  50. 56. Clinical findings
  51. 57. Examination of The Ankle and Foot <ul><li>Inspect the ankles and feet for: </li></ul><ul><ul><li>symmetry </li></ul></ul><ul><ul><li>deformity </li></ul></ul><ul><ul><ul><li>look for pes planus and pes cavus </li></ul></ul></ul><ul><ul><li>signs of inflammation and edema </li></ul></ul><ul><li>Palpate: </li></ul><ul><ul><li>gastrocnemius & soleus muscles </li></ul></ul><ul><ul><li>Achilles tendon </li></ul></ul><ul><ul><li>tarsals, metatarsals, phalanges </li></ul></ul><ul><ul><li>MTP, PIP and DIP joints </li></ul></ul><ul><li>Flex and extend the toes </li></ul><ul><ul><li>isolate the joints by stabilizing the ankle </li></ul></ul>
  52. 58. Physical exam – Ankle/foot <ul><li>Pertinent Positives and Negatives for ankle exam: </li></ul><ul><ul><li>edema, ecchymosis, erythema, effusion </li></ul></ul><ul><ul><li>lesions, rashes, masses, nodules. </li></ul></ul><ul><ul><li>deformity </li></ul></ul><ul><ul><ul><li>syndesmosis disruption </li></ul></ul></ul><ul><ul><li>tenderness </li></ul></ul><ul><ul><ul><li>plantar fascia </li></ul></ul></ul><ul><ul><ul><li>metatarsal squeeze test (Morton's neuroma) </li></ul></ul></ul><ul><ul><ul><li>Achilles squeeze test </li></ul></ul></ul><ul><ul><ul><li>bursitis (inflammatory, septic) </li></ul></ul></ul><ul><ul><ul><li>fractures (Jones, Pott's, talar dome) </li></ul></ul></ul>
  53. 59. Physical exam – Ankle/foot <ul><li>Pertinent Positives and Negatives for ankle exam: </li></ul><ul><ul><li>crepitus (where?) </li></ul></ul><ul><ul><li>stability </li></ul></ul><ul><ul><ul><li>ATFL, CFL, PTFL, deltoid ligament </li></ul></ul></ul><ul><ul><ul><li>anterior drawer </li></ul></ul></ul><ul><ul><li>ROM (active/passive) </li></ul></ul><ul><ul><li>muscle strength (active/passive) </li></ul></ul><ul><ul><li>neurological - sensory specific </li></ul></ul><ul><ul><li>vascular </li></ul></ul><ul><ul><li>Homan's test (DVT) </li></ul></ul>
  54. 60. Evaluation of ankle sprains, strains, & fractures <ul><li>A definitive evaluation of all sprains is important to R/O fracture </li></ul><ul><li>Sprains: </li></ul><ul><ul><li>partial or complete tear of the ligaments </li></ul></ul><ul><ul><li>graded 1-3 </li></ul></ul><ul><ul><li>most common injury of the ankle </li></ul></ul><ul><ul><li>inversion sprains make up the majority </li></ul></ul><ul><ul><li>eversion sprains may be more severe due to their association with syndesmosis injuries. </li></ul></ul>
  55. 61. Evaluation of ankle sprains, strains, & fractures <ul><li>Record a history of the cause of the injury. </li></ul><ul><ul><li>Ascertain the type of trauma: </li></ul></ul><ul><ul><ul><li>inversion/eversion </li></ul></ul></ul><ul><ul><ul><li>dorsiflexion/plantarflexion </li></ul></ul></ul><ul><ul><li>Determine whether the problem is acute, subacute, chronic, or of insidious onset. </li></ul></ul><ul><ul><li>Determine the severity and specific anatomic location of the pain </li></ul></ul><ul><ul><li>Document any present medication(s) </li></ul></ul><ul><ul><li>Document any history of systemic disease or previous ankle injury or disability </li></ul></ul>
  56. 62. Evaluation of ankle sprains, strains, & fractures <ul><li>Physical Examination: </li></ul><ul><ul><li>Assess the ability of the patient to bear weight, from no to full weight-bearing ability </li></ul></ul><ul><ul><li>Inspect for any evidence of an open or penetrating wound </li></ul></ul><ul><ul><li>Test the range-of-motion of the joint </li></ul></ul><ul><ul><li>Inspect for: </li></ul></ul><ul><ul><ul><li>deformity </li></ul></ul></ul><ul><ul><ul><li>tenderness </li></ul></ul></ul><ul><ul><ul><li>ecchymosis </li></ul></ul></ul><ul><ul><ul><li>associated nerve, neurovascular, or tendon injury </li></ul></ul></ul>
  57. 63. Evaluation of ankle sprains, strains, & fractures <ul><li>Physical Examination: (cont.) </li></ul><ul><ul><li>evaluate for evidence of joint instability </li></ul></ul><ul><ul><li>search for any evidence of dislocation or arterial vascular compromise </li></ul></ul><ul><ul><ul><li>cold, dusky foot with loss of sensation, pulse, and possibly sensation </li></ul></ul></ul><ul><ul><ul><li>if found, an immediate reduction should take place (prior to x-rays if necessary) </li></ul></ul></ul><ul><li>X-ray the ankle (two views) </li></ul><ul><ul><li>only if a fracture is suspected! </li></ul></ul><ul><ul><li>special views such as mortise should be obtained when necessary </li></ul></ul>
  58. 64. Case Study <ul><li>S: A 20-month-old toddler presents to the emergency department. Her parents state that she has been refusing to actively bear weight on her left leg for the last 3 hours. The child has attempted to walk during this period, but she has a noticeable limp and favors the affected leg. The patient no history of fever, and her parents deny any history of observed trauma. </li></ul><ul><li>Additional history? </li></ul><ul><li>BP 114/70 mm Hg; HR: 132 bpm, regular; RR: 24 breaths/min, no distress; Temp: 37°C A.D. </li></ul>
  59. 65. Case Study <ul><li>O: Well-developed toddler in mild distress. Alert and cooperative. Slowly ambulates with an antalgic gait. Her neck is supple without nuchal rigidity. Cardiac, respiratory, and abdominal findings are unremarkable. She has no evidence of erythema or warmth on the skin, no definite areas of tenderness, and no other evidence of trauma such as abrasions or lacerations. The patient is noted to have good range of motion of all joints in her extremities without obvious deformity or joint effusion. When the patient is asked to walk, she reluctantly attempts to take a few steps but does not fully bear weight on her left leg. </li></ul><ul><li>Laboratory results, including a CBC and an ESR, are WNL. </li></ul>
  60. 66. Case study <ul><li>Additional tests? </li></ul><ul><li>Diagnosis? </li></ul><ul><li>Treatment? </li></ul>
  61. 69. Clinical Findings <ul><li>Pump bump (Haglund’s deformity) </li></ul><ul><ul><li>thickening on the posterosuperior aspect of the calcaneus </li></ul></ul><ul><li>Hammertoe </li></ul><ul><ul><li>flexion deformity of the PIP joint on the 2 nd through 5 th toes causing hyperextension of the MTP joint </li></ul></ul><ul><ul><li>patients typically develop a boney prominence on the dorsum of the PIP joint </li></ul></ul><ul><li>Turf toe </li></ul><ul><ul><li>Hyperextension of the MTP joint of the great toe with possible tearing of the flexor tendon </li></ul></ul>
  62. 70. Anatomy of a Bunion (Hallux Valgus)
  63. 73. Recording the results <ul><li>Upright posture with a steady gait; fully weight bearing; no visible or palpable deformity; spine is midline with normal lordotic and kyphotic curvatures; no paravertebral tenderness; symmetrical muscle bulk and tone; grip strength is equal; strength is 5/5 bilaterally in upper and lower extremities; all joints are symmetrical and non-tender; no joint effusions, erythema, clubbing, cyanosis or edema; no crepitus on palpation; Full AROM/PROM in all joints; no ligamentous laxity; bilateral knee examination reveals patella is midline and freely moveable; no joint margin tenderness is present; no laxity with varus /valgus stress; anterior/posterior drawer sign is negative; Lachman’s/McMurray’s/Apley’s tests are negative. </li></ul>
  64. 74. Health Promotion <ul><li>Balanced nutrition </li></ul><ul><ul><li>calcium </li></ul></ul><ul><li>Regular exercise </li></ul><ul><ul><li>maintains (? increases) bone mass </li></ul></ul><ul><ul><li>stress management </li></ul></ul><ul><ul><li>disease prevention </li></ul></ul><ul><li>Maintain appropriate weight </li></ul><ul><ul><li>reduces mechanical wear on joints </li></ul></ul><ul><li>Household/occupational safety </li></ul><ul><li>Proper lifting </li></ul><ul><li>Fall prevention </li></ul>
  65. 75. Injury to the extensor mechanism of the finger at the DIP joint produces which of the following deformities? <ul><li>Boutonnière deformity </li></ul><ul><li>Mallet finger </li></ul><ul><li>Trigger finger </li></ul><ul><li>Swan neck deformity </li></ul><ul><li>Hammertoe </li></ul>
  66. 76. Finkelstein’s test is specific for which of the following conditions? <ul><li>Carpal tunnel syndrome </li></ul><ul><li>Bicipital tendonitis </li></ul><ul><li>De Quervain’s tendonitis </li></ul><ul><li>Trigger finger </li></ul><ul><li>Tear of the supraspinatus tendon </li></ul>
  67. 77. Wearing ill-fitting shoes may produce all of the following deformities except _______. <ul><li>Boutonnière deformity </li></ul><ul><li>Hammertoe deformity </li></ul><ul><li>Haglund’s deformity </li></ul><ul><li>Hallux valgus deformity </li></ul>
  68. 78. References <ul><li>Bickley, L.S. & Szilagyi, P.G. (2003). Bates’ Guide to Physical Examination and History Taking , 8 th Ed., Lippincott, Williams, & Wilkins. Philadelphia. pp. 465-533 </li></ul><ul><li>Seidel, H.M. et al. (2003). Mosby’s Guide to Physical Examination , 5 th Ed., Mosby. St. Louis. pp. 694-765 </li></ul><ul><li>DeGowin, R.L. Diagnostic Examination , 6 th Ed., McGraw-Hill. New York. pp. 619-753 </li></ul><ul><li> </li></ul>
  69. 79. Thought for the Day <ul><li>Success comes in cans </li></ul><ul><li>& </li></ul><ul><li>Failure comes in cant’s </li></ul>