Shoulder Examination Knee and Shoulder Examination David Kim, MD, FRCSC Orthopedic Surgery May 13, 2016 The shoulder is a ball and socket joint and is extremely mobile but also extremely unstable. The shoulder joint therefore relies on soft tissue restraints both dynamic (rotator cuff) and static (glenohumeral ligaments) to maintain stability. Inspection includes looking for skin changes, swelling, asymmetry, scars atrophy or scapular winging. The most common area to note atrophy is in the supraspinatus and infraspinatus fossae. Deltoid atrophy can also be seen by a flattening of the contour of the muscle. Shoulder dysfunction can lead to atrophy but severe atrophy usually indicates that there is a neurologic cause. A ganglion overlying the AC joint suggests that there is underlying arthritis of the AC joint. It can commonly be seen in large rotator cuff tears as well. Excessive swelling in the subacromial space is also indicative of a large or massive rotator cuff tear. Scapular winging can be caused by a long thoracic nerve palsy with weakness of the serratus anterior. Scapular winging will also be seen when glenohumeral motion is restricted. Tendon ruptures such as long head of biceps and pec tendon can be recognized by their classic deformities. Palpation of all bony landmarks and joints should be performed. In rotator cuff dysfunction, crepitus can often be felt in the anterior subacromial space immediately adjacent to the CA ligament. ROM is tested both actively and passively. 5 directions are typically measured. forward elevation angle between humerus and torso, external rotation at side, external rotation at 90 degrees abduction, internal rotation at 90 degrees abduction and internal rotation at side reach up spine. 1
Peripheral nerves: Axillary motor shoulder abduction sensory lateral upper arm Musculocuntaneous motor elbow flexion sensory lateral lower arm Median motor thumb and first finger flexion sensory index finger volar side Radial motor MP extension sensory first dorsal webspace Ulnar motor finger abduction sensory little finger volar side Neurovascular exam includes examination of the peripheral nerves and the nerve roots. 2
Nerve Roots.see ASIA table 3
Rotator cuff dysfunction leads to impingement due to an imbalance between the strength of the rotator cuff and the deltoid. This in turn leads to bursitis and acromial spurring. Rotator cuff dysfunction can be secondary to tearing, disuse, overuse, inflammation or neurological injury. How to detect rotator cuff dysfunction: Impingement tests: Neer Impingement Sign: Pain with passive forward elevation of the arm Hawkins Sign: Pain with shoulder flexion to 90 degrees and internal rotation Internal Impingement: Pain with arm in cocked position. Abducted and externally rotated. Rotator cuff tests: Subscapularis: Lift off test: Can t make a space between the back of hand and the back belly press: Cannot internally rotate arm with hand on belly. Increased passive ER Supraspinatus: Jobe s test: abduct arm 90 degrees and forward angle 30 degrees (in plane of scapula). Internally rotate so thumb is pointing to the floor. then press down on arm while patient resists. Drop Sign: Passively elevate arm to 90 degrees in plane of scapula. then ask patient to slowly lower their arm. Positive test is when the patient drops their arm. 4
Infraspinatus/Teres Minor: External rotation lag: Bring arm into maximal ER and the arm will drift back internally. Hornblower s sign: Place arm into throwing position. it will drift down into a bugler s position because they can t hold it up externally rotated. Labral/SLAP: O Brien s Test: arm is forward flexed 90 degrees and then adducted 15 degrees and held up against resisted first with arm pronated and then supinated. Positive if more pain when pronated. Crank test: Hold arm in abducted position. Apply axial compression while rotating arm Pain or clicking is a positive sign Biceps: Tenderness in the groove: Place hand in lap and the groove should be facing straight forward. Speed s: resisted forward elevation with arm supinated and elbow extended causes pain Yergason s Test: Resisted supination causes pain. Popeye: Indicated long head biceps rupture. AC Joint: Point tenderness over AC joint or positive cross body adduction. Pain with adduction of the shoulder across the front of the body. O Brien s test may be positive but the pain will be in the AC joint instead of deep in the glenohumeral joint. Instability: Load and shift: Loading the arm centres the humeral head in the glenoid and then an anterior or posterior force can be used to detect instability. Apprehension Test Relocation Test and Release: Supine, arm is external rotated and abducted. The patient will feel like the shoulder is going to pop out. A posteriorly directed force on the anterior shoulder will then relocate the shoulder and the patient should feel relief. When the force is subsequently released, the patient will be quite surprised to feel the apprehension again. This is a 3 in one test for anterior instability. 5
Posterior Jerk Test: Arm is forward 90 degrees, slightly adducted and internally rotated 90 degrees and push the humerus out the back when the shoulder is abducted, there will be a clunk as the shoulder jerks back into joint. Generalized Laxity: Beighton Score: elbow hyperextension thumb touches forearm little finger bends backward past 90 degrees. 6
Knee Examination The knee is a hinge joint with three main compartments. The medial tibiofemoral compartment, the lateral tibiofemoral compartment and the patellofemoral compartment. Examination can be guided by the history of presentation which can help narrow the focus of the physical examination. For example, a traumatic knee injury with a mechanism of injury such as a sudden stop or pivot accompanied by a pop and immediate swelling suggests that there is a hemarthrosis and that the likelihood of an injury to the ACL is extremely high. Examination of the knee usually starts with inspection. The appearance of the skin is noted along with the presence of scars, erythema or obvious swelling. Swelling can be recognized by comparing to the contralateral knee or by noting a loss of the normal contours. Baker s cysts will be visible posteriorly in the popliteal fossa. Atrophy is observed best by noting a flattening of the contour of the VMO or the Vastus Lateralis. It can also be measured objectively using thigh circumference. Any visual differences between legs are noted and the gait pattern is observed. An antalgic gait is one where the stance phase on that limb is shortened. Limb lengths discrepancies can be noted by observing pelvic obliquity. The alignment of the knee may be excessively bow legged (varus) or knocked kneed (valgus). Palpation of the bony landmarks comes next. The medial and lateral epicondyles along with the patella should be easy to find. The joint line is best palpated with the knee flexed to 90 degrees. This brings the patellar tendon under tension and the joint lines are located immediately adjacent to the patellar tendon in the soft spots. The patellar tendon and quads tendon can be palpated with the leg flexed as well. The iliotibial band can be tight where it crosses the lateral epicondyle. To check for an effusion, the milking test is very sensitive. The hand is brushed up the medial gutter of the knee and then brushed down the lateral gutter of the knee. If there is a effusion, then a fluid wave or a bulge coming back to the medial gutter will be seen. The patellar tap will be positive with larger effusions. Active and passive ROM is measured next and recorded as a flexion arc. Full extension to full flexion is 0-130 degrees. Many can hyperextend their knees so the extension portion would be recorded as a minus ie, minus 15-130 degrees. If there is a flexion contracture and the knee cannot completely extend, then extension portion is a plus ie, 20-130 degrees. One trick to tell if a flexion contracture is real or apparent is to ask the patient to walk backwards. An apparent flexion contracture will straighten out while walking backwards. Neurovascular examination should cover peripheral nerve and nerve root exam. 7
For peripheral nerve examination: Obturator sensation medial thigh motor thigh adduction Sciatic sensation posterolateral calf motor knee flexion Peroneal sensation dorsal foot motor toe extension Tibial sensation plantar foot motor toe flexion For the nerve root exam, the American Spinal Injury Association has a simple table that is very easy to follow 8
Vascular Examination includes checking pulses (popliteal, tibial and dorsalis pedis), examining for signs of venous insufficiency as well as arterial compromise (6 P s). Compartment syndrome needs to be ruled out. Pain, Pallor, Pulselessness, Poikilothermia, Paralysis, Parathesia. The ligaments are the primary restraints in the knee and provide stability. ACL: The Anterior Cruciate Ligament provides stability in the anterior to posterior plane but perhaps more importantly gives rotational stability. It prevents the tibia from shifting too far forward in relation to the femur which can be detected with an anterior drawer test or a lachmann test. The lachmann test is the most sensitive for ACL deficiency. The knee is brought into 20 degrees of flexion and the muscles must be relaxed. The leg must be supported. Increased anterior translation of the tibia in relation to the femur denotes a positive test. ACL deficiency will also lead to anterolateral rotational instability where the tibia is translating forward and internally rotating in relation to the femur. This can be detected with a pivot shift test or a flexion rotation drawer test which is the most specific test for ACL deficiency. With the knee in complete extension, a valgus and axial load is applied with the tibia internally rotated. When the knee is then brought into flexion, a clunk will be seen as the tibia reduces backwards. PCL: The Posterior Cruciate Ligament provides stability in the AP plane. It prevents the tibia from translating posteriorly in relation to the femur. PCL deficiency can be detected with a posterior drawer test, posterior sag or a quads active test. With the patient supine and the knees flexed to 90 degrees, a posterior sag of the tibia will be observed. In this same position, a posterior drawer force will improve the accuracy. Sometimes the tibia is sagging but it can t readily be appreciated on inspection. A quads active test will bring a posteriorly sagging tibia anteriorly and reduce it. With the knee flexed 90 degrees and the foot secured, the patient is asked to try and extend the knee. 9
MCL: The Medial Collateral Ligament provides stability primarily in the coronal plane. It prevents the knee from angulating into valgus. MCL deficiency can be detected by performing a valgus stress test. In 0 degrees of flexion, the bony constraints will prevent detection of valgus instability even when the MCL is torn. At 30 degrees of flexion, the bones are unlocked and isolated MCL tears can be detected with a valgus stress test. If the knee opens up to valgus stress even when the knee is fully extended, this suggests that there is a concomitant injury to the cruciate ligaments as well. LCL: The Lateral Collateral Ligament provides stability primarily in the coronal plane. It prevents the knee from angulating into varus. Isolated LCL tears are extremely rare and are usually associated with concomitant injuries to the posterolateral corner or the cruciate ligaments. Posterolateral Corner: Prevents posterolateral rotatory instability. Usually associated with LCL tears and cruciate tears. A varus thrust or hyperextension thrust may be noted during walking. Dial test increased external rotation of greater than 10 degrees compare with the other knee. If only at 30 degrees of flexion, most likely an isolated PLC injury. If increased ER seen at both 30 and 90 degrees of knee flexion, the PLC and PCL are both torn. External Rotation Recurvatum test will be positive when the leg falls into recurvatum and external rotation when the leg is held suspended by the great toe. Reverse Pivot Shift Test with the knee in flexion and external rotation with a valgus load applied, gradual extension will be accompanied by a clunk as the knee reduces forward from a posteriorly sublimed position. Always examine the peroneal nerve with lateral sided injuries Knee dislocations are accompanied by an extremely high incidence of vascular injuries Need to perform frequent vascular checks after a knee dislocation Meniscus: Only a bucket handle tear will give true locking where the knee becomes jammed in flexion and cannot be extended. Joint line tenderness is most sensitive. McMurray s is more specific but a positive McMurray s Test is not common. For medial meniscus externally rotate the tibia with knee flexed 90 degrees, apply valgus load and slowly extend the knee. A pop accompanied by pain is a positive test. For lateral meniscus, internally rotate the tibia with the knee flexed 90 degrees, apply a varus load and extend the knee. Appley s grind test with the patient prone and the knee flexed to 90 degrees apply axial load to the tibia and then rotate the tibia. For patellofemoral pathology, we look for signs of instability and signs of patellar compression. For instability, there may be increased lateral patellar translation noted. Lateral force on the patella with the knee flexed 20 degrees may give the patient a feeling as though the patella will dislocate (patellar apprehension sign). An increased Q angle or a positive J sign will predispose to patellofemoral issues. Patellar compression or excessive lateral patellar tilt may indicate patellofemoral compression syndrome. 10