Day 1 - LEG, FOOT AND ANKLE WORKSHOP

Transcription

1 Day 1 - LEG, FOOT AND ANKLE WORKSHOP NAME OF CLINICIAN: _ FOOT LANDMARKS TO BE DRAWN Achilles Tendon & Insertion Tibialis Posterior Tendon & Insertion (Navicular Tuberosity) First Metatarsophalangeal Joint Third Inter-Metatarsal Webspace LEG & ANKLE LANDMARKS TO BE DRAWN Ankle Joint Line Lateral Collateral Ligament a) anterior talo-fibular ligament b) calcaneo-fibular ligament c) posterior talo-fibular ligament Medial Collateral Ligament (Deltoid Ligament) Tip and Posterrior Edge of Medial Malleolus Tip and Posterrior Edge of Lateral Malleolus Base of the 5 th Metatarsal Location for Shin Splints (postero-medial tibia) EXAMINATIONS TO BE PERFORMED Thompson Test for Achilles Rupture Range of Motion of the First Metatarsophalangeal Joint Palpation of the Plantar Fascia Palpation of the Medial Calcaneal Tubercle 1

2 Day 2 - KNEE WORKSHOP NAME OF CLINICIAN: _ LANDMARKS TO BE DRAWN with Extended Knee Quads Tendon Patella Medial Retinaculum Tibial Tubercle with Knee Flexed to 90 degrees (foot flat) Patellar Tendon Medial & Lateral Divots Medial Joint Line Lateral Joint Line Head of Fibula Medial Femoral Epicondyle Lateral Femoral Epicondyle Medial Collateral Ligament Lateral Collateral Ligament Gerdy s Tubercle Ilio Tibial Band Pes Anserinus KNEE EVALUATIONS TO BE PERFORMED 2

3 A) Routine Office Visit B) Acute Knee Injury C) Hot Swollen Atraumatic Knee A) Routine Office Visit 1. Is the Knee warm? Place your palm over the knee! 2. Is there an Effusion? Squeeze the suprapatellar bursa and pinch both sides of knee! 3. Document ROM! Is there Pain At Extremes (PAE)? Crepitus? 4. Palpate the Medial and Lateral joint lines for tenderness ( especially posteriorly ) 5. Assess for Quad Atrophy (? visible VMO atrophy or measure circ 4 above patella ) 6. Check alignment for Varus / Valgus (in standing position) Based on Point Test Differential Diagnosis may be confirmed for the following: Anterior Quadriceps tendonitis palpate quadriceps tendon? tender P-F Syndrome tender antero-medially, heel-buttock distance, quads atrophy, assess Q angle, flat feet Patellar tendonitis palpate pateller tendon? tender Osgood-Schlatter disease palpate tibial tubercle? tender enlarged tubercle Pre-patellar Bursitis inspect & palpate pre-patellar bursa erythema/ swollen / tender? Medial Osteoarthritis & torn meniscus palpate medial joint line? tender Pes Anserne bursitis palpate pes anserine bursa? tender Meniscal Cyst inspect and palpate for mass, tender joint line Lateral OA & torn meniscus palpate for lateral joint line tenderness Meniscal Cyst inspect and palpate for mass, tender joint line ITB Friction Syndrome palpate for tenderness around lateral epicondyle Posterior Effusion squeeze the suprapatellar bursa and pinch both sides of knee! Baker s Cyst palpate for soft discreet mass or fullness posteriorly Sciatica assess for symptoms & signs of radiculopathy Hamstring tendonitis palpate hamstring tendons distally? tender Optional 1. If h/o remote injury or episodes of giving way, check ligaments (as in B next page) 2. If h/o giving way, check patellar stability (as in B next page ). Apprehension test / Q angle. B) Acute Knee Injury 3

4 SIX STEPS TO EVALUATE THE ACUTELY INJURED KNEE 1) Support knee with a can comfort and rapport 2) Evaluate for effusion or hemarthrosis 3) Check assisted ROM? Is the knee Locked? ( Is a minimum of degree arc of flexion present? ) 4) Evaluate Patella (Dislocation?) Medial Retinacular Tenderness Apprehension Sign ( Fairbanks) 5) Evaluate Extensor Mechanism (Rupture?) Observe active leg lift? Able? Palpate patellar tendon for defect Assess position of Patella?? high / Compare to unaffected side Palpate Quadriceps tendon for defect? 6) Evaluate Ligaments (Grade Tears 1-3) FIRST Define and Palpate the Medial & Lateral Joint Lines (begin with the divots) MCL Sprain palpate MCL for tenderness, & 30 degrees LCL Sprain palpate LCL for tenderness, & 30 degrees ACL Tear perform Lachman Test ( Not Drawer ) PCL Tear assess for Sag sign? compare to other knee C) Hot Swollen Atraumatic Knee (Infection, Gout, Rheum) 4

5 Inspection: acute synovitis ( infection, gout ) not visually impressive vs septic pre-patellar bursitis looks angry & red) Is the Knee hot? Place your palm over the knee! Any Constitutional symptoms? Is there a fever? Is there an Effusion? squeeze the suprspatellar bursa and pinch both sides of knee! Document ROM? Is there severe pain with movement? septic arthritis? Day 3 - LOW BACK AND HIP WORKSHOP NAME OF CLINICIAN: _ 5

6 TESTS TO BE PERFORMED FROM BEHIND Patient Points to Most Painful Area Observe for Masses, Scoliosis, Asymmetry Palpate Iliac Crests (level of L4) Assess for leg length discrepancies Palpate Spinous Process L4-S1? step? Palpate Sacroiliac Joints Observe ROM, FLEX, hold extension 10 seconds FROM IN FRONT Observe heel walking Observe unilateral toe raises 5 times Observe ability to get up on table SUPINE Check abdomen Check ROM hip, esp. Internal Rotation Do passive SLR and Record if <60 Do Femoral Nerve stretch test ( if appropriate ) Do Neuro Exam: Sensory L1-S1 Motor L4-S1 Reflexes L4 & S1 Palpate Greater Trochanter Simulate Injection Greater Trochanter Do rectal and perianal sensation (Only if Cauda Equina Syndrome suspected) Primary Care History for Low Back Pain Nowhere in medicine is a careful history more valuable than in the evaluation of low back pain. In the vast majority of cases a carefully focused history will exclude serious disease as a cause of low back pain and allow the clinician to effectively manage the problem. The physical exam, imaging and consultations rarely add 6

7 information not readily available by taking a focused history. Ninety-nine percent of acute low back pain is mechanical, benign and self-limiting. We can rule out rare serious causes of low back pain (fracture, tumor, infection, and serious neuro problems) by asking key questions to raise Flags. Recommended history for primary care Age and occupation recorded before interview 1. When did your low back pain begin? 2. Have you had similar episodes before, or? How is this one different? (If young male, ask if morning stiffness is a significant problem. 3. Does this involve your back only or back and leg(s)? Which is a bigger problem to you, back or legs? If leg pain present, does coughing or walking aggravate it? Do you have pain down the back of thighs to calf, or from the groin to the knee? Neuro 4. Is there any perianal numbness or weakness or numbness in your legs or feet? Any problem with bowel or bladder control? Dribbling? Soiling underwear? If pain or numbness in feet, outline area of foot with your finger. Inf/tumor 5. Is the pain constant or mechanical (mechanical pain is pain that is intermittent and aggravated by activity and relieved by rest. If mechanical, go to #6. If constant, expand by asking.) Does it awaken you at night? Cause you to walk around? Do you feel well other than low back pain? Any fever, chills, weight loss? History of cancer, diabetes mellitus, recent infection especially urinary tract infection? Fx 6. Was there an injury or event (date?) that preceded pain? (No #7.) Yes? Evaluate for fracture, ask: 1) Magnitude of injury, 2) history of cancer, 3) use of steroids, 4) other cause of osteoporosis. (If no fracture, tumor, infection or serious neuro problem suspected, ask #7 to #10.) 7. What does your low back pain prevent you from doing that you need to do? 8. What most concerns you about the pain you arte having? 9. What treatment have you tried or been given up to now? (Heat, rest, meds, PT). What has worked or not for you? 10. Is this a work-related injury? Is litigation involved? 11. Has there been any significant change in your work or personal live? Are you stressed out? Has there been any significant change in you work or personal life? Primary Care Physical Examination for Low Back Pain The recommended P/E can be performed in less than 5 minutes. It is structured for the purpose of gaining information that allows the clinician to provide appropriate advice and counseling as 7

8 much as it is to clarify the diagnoses. In consideration of the discomfort of the patient and for the economy of time, it is suggested that the examination be divided into the Standing part and the Supine part. Standing exam from behind: the patient stands with back exposed and clinician sits behind patient. (a) Have the patient point to the area of maximal pain. (b) Place your hands on the Iliac crests and compare height of each to assess for leg length inequality. Palpate the spinous processes of L1 to S1 (L4 is top of crest) and check for steps suggestive of spondylolisthesis. (c) Observe for sciatic scolioses, masses and asymmetry. (d) Ask the patient to bend forward as though to touch the toes, being careful not to hurt him/herself: observe flexibility vs. rigidity in lumbar spine. Standing exam from in front: Holding the patients hands for balance, ask the patient to walk on heels (L4 and L5), then ask to do unilateral toe raises 3 times each side (S1). Measure chest expansion with tape if young male with morning stiffness. Supine exam: (a) Check abdomen for aneurysm, etc. if appropriate. (b) Do Range of Motion Hips esp. int. Rotation to R/O hip disease as a cause of buttock and anterior thigh pain. (c) Check ankle (S1) and knee (L4) reflexes and compare. (d) Do passive Straight Leg Raising by raising heel and noting at what angle patient experiences pain below the knee. Note if raising one leg causes pain in other limb. (e) Check sensation with pin (sharpness) in 1 st web space (L5) and lateral side of foot (S1). (f) Check strength of big toe extension (L5) ankle dorsiflexion (L4 and L5) and knee extension (L3 and L4) on side with sciatica. (g) Do femoral nerve stretch test if patient has anterior thigh pain or if L3, L4 disc suspected. (h) Do rectal exam to assess sensation and tone if cauda equina syndrome suspected. Day 4 - Mini Exam, Shoulder & Cervical Spine Workshop NAME OF CLINICIAN: _ SHOULDER and CERVICAL SPINE LANDMARKS TO BE DRAWN 8

9 Scapular Spine Lateral Margin of Acromion Acromion Process Subacromial Space Clavicle Acromioclavicular Joint Sternoclavicular Joint Supraspinatus Muscle Infraspinatus Muscle Medial Border Scapula Trapezius Muscle Coracoid Process Biceps Tendon, Long Head Spines of Cervical Vertebrae C5, C6, C7 TURN OVER TO NEXT PAGE SHOULDER & CERVICAL SPINE TESTS TO BE PERFORMED Basic Mini Exam: 9

10 Ask patient to point with a finger to the painful area Observe and touch for heat, masses, and asymmetry Palpate Rotator Cuff in the subacromial space AC Joint Cervical Spine Spinous Processes Trapezius Muscle The tender spot Compare ROM between Cervical Spine & Shoulder: After ROM of each, ask patient to grade pain on a scale from 1 to 10. Which hurts more? Shoulder or Cervical Spine Based On The Mini Exam, Evaluate the Shoulder vs Cervical Spine vs Referred Pain Shoulder Modified Impingement Sign* - Kiss Elbow, and check lateral rotation Impingement Sign* (Neer) Apprehension Sign (anterior instability) Relocation Test* (anterior instability ) Lateral Rotation ROM Test* (frozen shoulder) Scapular Stabilization Test* (frozen shoulder) Thumbs Down Abduction Test* (rotator cuff tear) Lateral Rotation Strength Test* (rotator cuff tear) Simulate Subacromial and A-C Injection Palpate tender/prominent AC Joint (OA or separation) *Diagnosis Specific Exam SHOULDER & CERVICAL SPINE TESTS TO BE PERFORMED Basic Mini Exam: Ask patient to point with a finger to the painful area 10

11 Observe and touch for heat, masses, and asymmetry Palpate Rotator Cuff in the subacromial space AC Joint Cervical Spine Spinous Processes Trapezius Muscle The tender spot Compare ROM between Cervical Spine & Shoulder: After ROM of each, ask patient to grade pain on a scale from 1 to 10. Which hurts more? Shoulder or Cervical Spine Based On The Mini Exam, Evaluate the Shoulder vs Cervical Spine vs Referred Pain Cervical Spine check when complete Referred Pain Sensory C5 - T1 Motor C5-T1 Reflexes C5, C6, C7 Diagnosis Dependent Exam CERVICAL SPINE NEURO EXAM Sensory C5 Lateral Upper outer arm 11

12 C6 First palmer webspace (6 shooter) C7 tip of long (3 rd ) finger C8 tip of little (5 th ) finger T1 medial elbow to upper inner arm Motor C5 Deltoid C6 thumb side of wrist extension C7 Triceps C8 Long Finger Flexors T1 Finger abduction (scissors) Reflexes C5 Biceps C6 Brachioradialis C7 Triceps But if Mini Exam = C-Spine Patient points to trapezius, neck, medial border scapula Observe and feel: tender as above Palpation: tender C-Spine, Trapezius, and THE tender spot ROM: C-Spine shows less ROM than shoulder, grimacing more, and pt rate s neck pain out of 10 higher than shoulder 12

13 Cervical Spine: three kinds of problems Neck pain only Neck pain and arm pain Cord lesions with upper motor neuron signs Neck Pain Only Treatment entirely empirical Patient s belief system critical Encourage early activities Neck Pain with Arm Pain Brief neuro exam essential ROM, palpation, inspection already done in Mini Exam Reflex motor and sensory exam required 13

14 Neuro Exam REFLEXES: Biceps-C5, Brachioradialis-C6, Triceps-C7 MOTOR: check strength of; elbow flexion = C5, wrist dorsiflexion=c6, elbow ext.=c7, claw fingers=c8, spread fingers=t1 SENSORY: C6=six shooter, C5=deltoid, C7=tip of long finger, C8=side of hand, T1=medial upper arm But if Mini Exam Suggests Referred Pain Pain free ROM of shoulder and C-Spine Constitutional systems Manage specific disease TABLE 2-1. Upper Extremity (C5-T1) Nerve Root Examination Nerve Root Disc Level Motor Sensory Deep Tendon Root C5 C4-C5 Shoulder Abduction Lateral Arm Biceps C6 C5-C6 Elbow Flexion Lateral forearm and thumb Biceps Wrist extension C7 C6-C7 Elbow Extension Wrist Flexion Finger (MCP joints) Middle of hand including middle finger Brachioradial Triceps 14

15 extension C8 C7-T1 Finger (MCP joints) flexion T1 T1-T2 Finger abduction/adduction Medial forearm and small finger Medial arm None None SUMMARY OF APPROACH TO SHOULDER PAIN Hx and Mini Physical Exam 15

16 C-Spine vs. Shoulder vs. Referred Brief Diagnosis Diagnosis Neuro Specific Dependent Exam Exam Exam Day 5 - ELBOW WORKSHOP NAME OF CLINICIAN: _ ELBOW LANDMARKS TO BE DRAWN Lateral Epicondyle Medial Epicondyle Olecranon Process Tip 16

17 Radial Head Ulnar Grove Distal Biceps Tendon Common Extensor Origin Common Flexor Origin ELBOW TESTS TO BE PERFORMED Exam for Pain At Extremes [PAE] Wrist Resistance Test for Extensors Wrist Resistance Test for Flexors Palpate [Push On] Radial Head Tap Ulnar Nerve Palpate Ulnar Nerve Supination Strength Palpate Distal Biceps Simulate Tennis Elbow Injection Day 5 - WRIST AND HAND WORKSHOP NAME OF CLINICIAN: _ WRIST AND HAND LANDMARKS TO BE DRAWN Distal palmar crease (landmark for injecting trigger finger) Proximal palmar crease (landmark for injecting trigger finger) Thumb crease (landmark for injecting trigger finger) Palmaris Longus (landmark for median nerve & injecting carpal tunnel) 17

18 Radial Styloid First Dorsal Compartment Snuff Box Transverse Carpal Ligament: Carpal Tunnel EXAMINATIONS TO BE PERFORMED Brief Sensory Exam: Median ( sensation present palmar tip of the thumb ) Ulnar ( sensation present palmar tip of little finger Radial ( sensation present on dorsum of the hand ) Brief Motor Exam: Median ( if patient can flex the thumb ) Ulnar scissors the index and middle fingers together & apart ) Radial ( if patient can extend the thumb ) Finklesteins Test Thumb CMC Grind Test Tinels Test Carpal Tunnel (Median Nerve) Compression Test Phalens Test 18