Michael Brickens, PT IU Health/Methodist Emergency Medicine Trauma Center MUSCULOSKELETAL EXAMINATIONS

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1 Michael Brickens, PT IU Health/Methodist Emergency Medicine Trauma Center MUSCULOSKELETAL EXAMINATIONS

2 Outline Terminology Musculoskeltal System review Anatomy Imaging? Ankle Exam Knee Exam Shoulder Exam Treatment considerations Lab Q & A

3 Sensitivity Ability to identify patients with particular disorder Ability to correctly identify positives SnNout: Sensitivity Negative rules Out If test is (-), low probability of having disorder Specificity Ability to identify patient without particular disorder Ability to correctly identify negatives SpPin: Specificity Positive rules In If test is (+), high probability of having disorder

4 Condition (Gold standard result) Positive Negative Test Outcome Positive True Positive False Positive Negative False Negative True Negative PPV NPV Sensitivity Specificity

5 Predictive Value Positive: proportion of patients with positive diagnoses that truly have the disorder Negative: proportion of patients with negative diagnosis that truly do not have the disorder

6 Likelihood Ratio Positive: probability shift to the patient does have the disorder Negative: probability shift to the patient does not have the disorder (+) LR (-) LR Interpretation of probability shifts >10 <0.1 Large & often conclusive shifts Moderate shifts Small but sometimes important shifts Small & rarely important shifts

7 The Musculoskeletal System System is comprised of 206 bones that provide the framework for the body and protect various organs Also includes soft tissue, which includes cartilage, tendons, ligaments and muscles

8 Musculoskeletal Overview Bones, cartilage, tendons, and ligaments are all connective tissue consisting of living cells, non living protein fibers and an amorphous ground substance

9 Other things that make up the Musculoskeletal System Tendons connect muscle to bone have good blood supply and heal well Ligaments- connect bone to bone, indirect blood supply and have a longer healing time Both of these have great tensile strength Joints-union of two or more bones Bursae-cushion of joints

10 Other Components Bursae: located between bones, tendons and ligaments that move against each one another, prevents friction Menisci: fibrocartilage structures of crescent shape that are thought to be formed in fetal development

11 Types of Joint Movement Flexion: bending of joints that decrease angle between 2 bones Extension: bending of joint that increases angle between two bones Hyperextension: extension in which the angle exceeds 180 degrees Dorsiflexion: movement of the body part up toward the dorsum Plantarflexion: flexion of the ankle down toward the ground Abduction: movement of part away from midline Adduction: movement of part toward midline Pronation: turning downward Supination: turning upward Circumduction: combinations of flexion, extension, abduction and adduction resulting in circular motion of the body part

12 History/Interview The medical interview or consultation influences the precision of diagnosis and treatment, and studies have indicated that over 80% of diagnoses in general medical clinics are based on the medical history Physicians themselves have contributed to a culture of medical practice in which objective test results are given more credence and are felt to be more reliable than the subjective story of the patient or assessment of the physicians J Gen Intern Med January; 14(S1): S26 S33.

13 5 Minute Consultation. Less time, otherwise, will mean less relating time and damage to care: less-accurate and incomplete data; difficulty in identifying the real problems; less efficiency in test and treatment choices based on knowledge of the individual patient; less trust; less healing; more errors and more waste Tamblyn R, Berkson L, Dauphinee WD, Gayton D, Grad R, Huang A, Isaac L, McLeod P, Snell L Ann Intern Med Sep 15; 127(6):

14 Listen Listen to the patient s answer without interrupting. Studies show that clinicians interrupt patients during office visits after only 18 seconds! If patients are allowed to tell their stories, most will finish within 2 minutes Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 101(5): ,1984

15 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G History/Patient Interview The Seven Attributes of a Symptom ATTRIBUTES OF A SYMPTOM 1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) 4. Timing. When did (does) it start? How long does it last? How often does it come? 5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Is there anything that makes it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it?

16 EXPLORING THE PATIENT S PERSPECTIVE The patient s thoughts about the nature and the cause of the problem The patient s feelings, especially fears, about the problem The patient s expectations of the clinician and health care The effect of the problem on the patient s life Prior personal or family experiences that are similar Therapeutic approaches the patient has already tried

17 Conclusion of Interview Summarization Giving a capsule summary of the patient s story during the course of the interview can serve several different functions. It indicates to the patient that you have been listening carefully. It can also identify what you know and what you don t know. Anything else?

18 Mechanism of Injury Was there an injury? Describe the mechanism? Immediate swelling? Care provided prior to presentation to clinic? Ice, heat, OTC or prescriptions taken Prior injuries? Prior treatment? If no injury?

19 Perils of Orthopedics Explain what you are going to be doing. Always examine the normal extremity first Establishes rapport/familiarity with patient Gives examiner a baseline for normal ROM Flexibility Strength Joint Laxity Bony Landmarks DON T JUST PALPATE or Poke

20 Upper or Lower Quarter Screen If no injury.should be done Cervical- for shoulder, elbow wrist and hand Lumbar hip, knee, ankle and foot. Dermatomes, Myotomes, Reflexes!!

21 Ankle Anatomy

22 Ligaments and attachments

23 Muscles and Tendons

24 Squeeze Test To perform the squeeze test, compress the midleg from posterior lateral to anterior medial. The squeeze test is used to identify disruption of the tibiofibular syndesmosis (the interosseus membrane between the tibia and fibula).

25 Talar Tilt Perform the talar tilt test with the ankle in both the neutral position (A) and in plantar flexion (B). With the patient seated, secure the lower leg with one hand and grasp the forefoot with the opposite hand. Apply an inversion force to produce a talar tilt

26 Anterior Drawer The anterior drawer test also assesses the integrity of the ATFL. While the patient is seated, grasp the lower leg with one hand and the forefoot with the other. Then, apply an anterior force to produce forward translation rqok1ak&feature=relmfu

27 Achilles Tendon Rupture/

28 Ottawa Ankle Rules Ankle radiographs are indicated if there is pain in the malleolar region and any of the following: 1. Tenderness of posterior edge of distal 6 cm or tip of lateral malleolus, or 2. Tenderness of posterior edge of distal 6 cm or tip of medial malleolus, or 3. Unable to bear weight (4 steps) both immediately after the injury and at the time of evaluation

29 Ottawa Ankle Rules Foot radiographs are indicated if there is pain in the midfoot region and any of the following: 1. Tenderness of the navicular bone 2. Tenderness at the base of the 5 th metatarsal 3. Unable to bear weight (4 steps) both immediately after the injury and at the time of evaluation

30 Treatment Considerations PRICE Protection-Ankle stirrup Rest- Relative Rest/Restrictions Ice- Compression-ace/tubigrip Elevation AROM-focusing on ankle DF Crutches- quality gait Camboot

31 Knee Injuries GegA&feature=related Graphic Injury don t watch if you get squemish

32 Knee Anatomy

33 Knee Anatomy

34 Knee Bursae

35 The Ottawa knee rules are a set of rules used to help physicians determine whether an x-ray of the knee is needed. [1] They state that an x-ray is required only in patients who have an acute knee injury with one or more of the following: Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex to 90 Inability to bear weight both immediately and in the emergency department (4 steps

36 Ottawa Ankle Rules

37 Patella Fracture

38 Ligamentous Injury Grade 1 symptomatic stretch within the tensile limit but without failure. Grade 2 exceeds the limits of tensile strength, with failure of part of the ligament fibers. Grade 3 complete failure of the ligament fibers..

39 Varus Stress- LCL Knee Relaxed 30 degress of knee flexion Stabilize femur Apply adduction force to Lateral lower leg

40 Valgus Stress-MCL

41 Lachmans/Ant Drawer- ACL

42 Meniscus tests

43 Meniscal-Thessally

44 Patellar Instability

45 Test Sensitivity Specificity Anterior Drawer (http://www.youtube.com/watch?v=zlisiekdn0o) Lachman (http://www.youtube.com/watch?v=5_zuezew9rk&feature =related) Pivot Shift (http://www.youtube.com/watch?v=ilmwpup_6hs ,10, ,10, ,10, ,10, ,10, ,10,22

46 Test Sensitivity Specificity Posterior Drawer (http://www.youtube.com/watch?v=mryevbrrl1k&feature=c hannel)

47 Test Sensitivity Specificity Valgus Stress (http://www.youtube.com/watch?v=j_ke0bmsjxe) No Research Found

48 Test Sensitivity Specificity Varus Stress (http://www.youtube.com/watch?v=kzm5vehkmpq&featur e=channel) No Research Found

49 Test Sensitivity Specificity Positive LR Negative LR McMurray (http://www.youtube.com/watch? v=irg3cb4jae8&feature=related) Joint Line Tenderness ,14,21, ,14,21, ,14, ,14, Thessaly(http://www.yo utube.com/watch?v=84pzh0n_rm g) Ege s (http://www.youtube.com/watch? v=9uggmjg9kpc&feature=channel ) Medial Meniscus Lateral Meniscus Apley-Grinding (http://www.youtube.com/watch? v=at0fdkhacgo&feature=related) , , , , , ,

50 Test Sensitivity Specificity Moving Patellar Apprehension (http://www.youtube.com/watch?v=xj1q7panifq)

51 Test Sensitivity Specificity Patellar Tendon Palpation

52 Treatment considerations Ace Wrap Hinged Knee Brace Cryotherapy NSAIDS Restrictions? ROM Strengthening? Crutches/Cane Immobilizer?

53

54 Imaging? Fall

55 Rotator Cuff Tear?

56 Tendonopathy (itis)

57 Internal Derangement-SLAP

58 Shoulder Instability

59 Treatment Considerations Ice Sling Clavical Strap NSAIDS Restrictions Exercises Imaging?

60 Test Sensitivity Specificity Likelihood Ratio Apprehension , , Relocation Surprise Cluster Test of 3 tests above: PPV: 93.6% 18 NPV: 71.9% 18

61 Test Sensitivity Specificity Positive LR Negative LR PPV NPV Neer (http://www.youtube.com/watch?v= k21fntbjq14) Hawkins- Kennedy (http://www.youtube.com/watch?v= 2mSv7gLXyYg&feature=channel) Painful Arc , , Empty Can (http://www.youtube.com/watch?v= tqv3yxucbhg) External Rotation Resistance Drop Arm

62 Cluster Test (Hawkins-Kennedy, Painful Arc, & Infraspinatus Muscle Test): (+) LR: (-) LR:

63 Test Sensitivity Specificity Positive LR Negative LR MRI Ultrasound Drop Arm Test Painful Arc Infraspinatus Test (http://www.youtube.com/watch? v=eziziwgctq4) Empty Can Cluster Test (Drop Arm, Painful Arc, Infraspinatus Test): All (+) +LR: All (-) LR:

64 Test Sensitivity Specificity Positive LR Negative LR O Brien Active Compression (http://www.youtube.com/watch? v=0qbnrozdfwy) Biceps Load II (http://www.youtube.com/watch? v=h2iyvaceypk&feature=channel) Crank Test (http://www.youtube.co m/watch?v=3clvoc21ht o&feature=channel) Resisted External Rotation ,19, ,19, , ,

65 Test Sensitivity Specificity Positive LR Negative LR Speeds (http://www.youtube.com/watch? v=n00ga4pvsbw&feature=related) ,11, ,11, Yergason s (http://www.youtube.com/watch? v=rq2mp6asi88&feature=related) ,

66 Test Sensitivity Specificity Positive LR Negative LR Cross Body Adduction (http://www.youtube.com/watch? v=gj7kjfr8eta) O Brien Active Compression

67 1. Ahmad CS, McCarthy M, Gomez JA, Shubin Stein BE. The moving patellar apprehension test for lateral patellar instability. Am J Sports Med 2009; 37(4): Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray s test and joint line tenderness. Arthroscopy 2004; 20(9): Benjaminse A, Gokeler A, vander Schans CP. Clinical diagnosis fo an anterior cruciate ligament rupture: a metaanalysis. J Orthop Sports Phys Ther 2006; 36(5): Calis M, Akgun K, Birtan M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000; 59: Chronopoulus E, Kim TK, Park HB et al. Diagnostic value of physical test for isolated chronic acromioclavicular lesions. Am J Sports Med 2004; 32(3): Cook JK Khan KM, Kiss ZS et al. Reproducibility and clinical utility of tendon palpation to detect patellar tendopathy in young basketball players. Br J Sports Med 2001; 35(1): Dessaur WA, Magarey ME. Diagnostic accuracy of clinical tests for superior labral anterior posterior lesions: a systematic review. J Orthop Sports Phys Ther 2008; 38(6): Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technology Assessment 2003; 7(29): Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder stability. J Bone Joint Surg Am 2006; 88(7): Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination. Buckner, KY: Evidence in Motion; Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. Physical examination for partial tears of the biceps tendon. Am J Sports Med 2007; 35(8): Gaunche CA, Jones DC. Clinical testing for tears of glenoid labrum. Arthroscopy 2003; 19(5):

68 13. Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clin J Sport Med 2009; 19(1): Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta analysis. J Orthop Sports Phys Ther 2007; 37(9): Holtby R, Razmjou H. Accuracy of the Speed s and Yergason s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 2004; 20(3): Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy 2001; 17(2): Litaker D, Pioro M, El Bilbeisi H et al. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am Geriatr Soc 2000; 48(12): Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. Am J Sports Med 2004; 32(2): McFarland EG, Kim TK, Savino RM. Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med 2002; 30(6): Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Arch Phys Med Rehabil 2009; 90: Ockert B, Haasters F, Polzer H, et al. Value of the clinical examination in suspected meniscal injuries. A meta-analysis. Unfallchirurg 2010; 113(4): Ostrowski JA. Accuracy of 3 diagnostic tests for anterior cruciate ligament tears. J Athl Train 2006; 41(1): Sae-Jung S, Jirarattanaphochai K, Benjasil T. KKU knee compression-rotation test for detection of meniscal tears: a comparative study of its diagnostic accuracy with McMurray test. J Med Assoc Thai 2007; 90(4): Stetson WB, Templin K. The crank test, the O Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med 2002; 30(6): Teefey SA, Rubin DA, Middleton WD et al. Detection and quantification of rotator cuff tears: comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am 2004; 86(4):

69 Thanks for your attention!

70 Contact Information Michael Brickens, PT

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