Download Shoulder, Hip and Knee Pain and Assessment Disclosure Topics

Disclosure
Shoulder, Hip and Knee Pain and Assessment
Jackie Rowles, MBA, CRNA, ANP‐BC, FAAPM, FAAN
Advanced Physical Assessment for Differential Diagnosis
In Pain Management
AANA May 2015
 I have no financial relationship with any commercial interest related to the content of this course
 I may discuss off label use of medications during my presentation or during Q/A. I will disclose any such reference.
Topics Covered
Shoulder and Shoulder Pain
 Shoulder
 Hip
 Knee
 Moves in every direction: flexion, extension, abduction, adduction, internal/external rotation
 The arm (humerus) hangs from the scapula via the joint capsule, intra‐articular capsular ligaments, glenoid labrum, and a web of muscles and tendons
 Made up of 4 joints, 3 large bones, 3 muscle groups called the shoulder girdle  Stabilized by the clavicle and acromion
Shoulder
Shoulder Joint(s)
 Glenohumeral
 Sternoclavicular
 Acromioclavicular (AC)
Shoulder Muscle Groups
SITS muscles
 Scapulohumoral – from scapula to humerus – SITS 
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Supraspinatus (arm abduction)
Infraspinatus (arm external rotation)
Teres major (arm external rotation)
Subscapularis (internal rotation of humerus)
 Function: Rotate the shoulder laterally, causes depression of rotation of humeral head = “rotator cuff”
Rotator Cuff
 Muscle and tendon group that stabilizes the shoulder, glenohumeral joint
 Tendons at end of muscles may become torn with pain and decreased ROM
 Most commonly supraspinatus  Injuries occur with repeated overhead motion or forceful pulling motion (think athletes, conductors, drummers)
 Resultant impingement syndrome
Impingement syndrome
 Impingement syndrome also called: subacromial or supraspinatus syndrome, swimmer’s shoulder, thrower’s shoulder
 Rotator cuff tendon inflammation
 Irritated tendons travel under acromion  Resultant pain, weakness, decreased ROM Drop Arm Test ‐Rotator Cuff Tear
Shoulder Muscle Groups
 Axioscapular Group
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Tear in supraspinatus muscle/tendon
Passive abduction of shoulder to 90 degrees
Ask Patient to slowly lower the arm
If arm “drops” it is a positive test
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Trapezius
Rhomboid
Serratus Anterior
Levator Scapulae
 Function: Rotate the Scapula which pulls the shoulder posteriorly
Posterior Shoulder Muscles
Shoulder Muscle Groups
 Axiohumeral Group
 Pectoralis Major
 Pectoralis Minor
 Latissimus Dorsi
 Function: Internal rotation
Anterior Shoulder Muscles
Note: Biceps/Triceps
 While technically not part of the “shoulder girdle” these muscles are involved in shoulder abduction
Shoulder bursa
Subacromial bursa
 Subacromial bursa pain (bursitis)
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Abduction compresses this bursa sac
Inflammation allows for palpation
Pain with abduction and rotation
Jerky movement or loss of smooth sliding feeling
Shoulder evaluation
Shoulder ROM
 Inspection – swelling, deformity, muscle atrophy, fasiculations, position (scoliosis may elevate one side, dislocation anteriorly flattens the normally rounded lateral aspect, dislocation posteriorly flattens anterior area and prominence of humeral head is increased)
 Palpation – note where pain is elicited
 Raise arms to 90 degrees (abduction=glenohumeral)
 Raise arms to diving position above head (combination of scapulothoracic motion to 60 and glenohumeral/scapulothoracic motion last 30 degrees)
 Position hands behind neck with elbows out (external rotation and abduction)
 Position hands behind low back (internal rotation and adduction)
 Top and toward neck most likely is AC joint
 Lateral and to deltoids most likely is rotator cuff
 Anterior most likely is bicep tendon pain
Shoulder evaluation
 AC joint – crossover test (inflammation or arthritis)
 Bursa (subacromial, subdeltoid) DJD, calcium deposits, tear
 Rotator cuff – palpate SIT
Supraspinatus – under acromion
Infraspinatus – posterior to supraspinatus
Teres Major – posterior and inferior to supraspinatus
drop‐arm sign – raise arm to 90 degrees and slowly lower to check for a tear or disorder
Shoulder evaluation
 Bicipital groove/tendon – position elbow against body with forearm flexed to right angle. Have patient supinate against your resistance to check for pain
 Glenohumeral joint – palpate joint capsule and synovial membrane inferior to the anterior and posterior acromion (normally cannot palpate capsule or membrane margins unless a large effusion is present)
Hip
 Primary flexor is iliospsoas muscle
 Innervation: T12, L1, L2, L3
 Muscle test: sitting thigh lift
 Primary extensor is gluteus maximus
Hip
 Adduction – muscles arise from rami of pubis/ischum and insert on posteriomedial femur
 Adductors: brevis, longus, magnus
 Innervation L2, L3, L4 (obturator nerve)
 Abduction – muscles from iliac crest to head of femur – gluteus medius and minimus. Stabilize gait
Hip bursa
 Anterior: psoas bursa over hip capsule and psoas muscle
 Greater trochanter (GT): bony prominence lateral to hip joint
 Ischiogluteal bursa – under ischial tuberosity: “sit bones” may mimic sciatic pain, may not be present, usually not palpable unless inflamed
Hip adductor/abductor
Hip evaluation
 Observation: gait
 Subjective information: hip pain, groin pain  Inspection and ROM: flexion, extension, abduction, adduction, rotation
 Palpation
Hip ROM ‐‐ supine
 Flexion – hand under lumbar spine, one knee to chest
 Extension – (prone) lift thigh posteriorly
 Abduction – stabilize opposite anterior pelvis with hand, hold ankle and move leg laterally until iliac spine moves
 Adduction – stabilize pelvis with one hand, hold ankle and move leg medially across/over other leg
 Rotation – leg flex to 90 at hip and knee, hold ankle and rotate leg medially (external) to laterally (internal)
Hip ROM
 Arthritis is most common cause of restriction.  OA usually presents as pain with abduction.  Lack of flexion may be due to increased lumbar lordosis or pelvic tilt, watch to see if opposite leg can maintain a flat position with flexion of the other Knee Anatomy and Pain
Knee
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Largest joint in body
Hinge joint: femur, tibia, patella
Articular parts: femur:patella, 2 parts of tibia:femur
Only stable due to the ligaments which hold the bones in alignment
 No padding from fat or muscles
Knee
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Landmarks
Structures to palpate/identify/mark
Go to shin, move anterior to tibial tuberosity (midline)
Go medial, move anterior to medial condyle Go to opposite side and inferiorly to lateral condyle Below lateral condyle, palpate head of fibula
Patella is located anterior femur surface, within the quadriceps muscle tendon which runs below the knee joint as the patellar tendon
The Knee
Knee
 Important Muscle groups – Quadriceps, Hamstrings
 Ligaments
 Medial Collateral (MCL) – medial stability
 Lateral Collateral (LCL)– lateral stability
 Anterior Collateral (ACL) – prevents tibia from sliding forward over femur
 Posterior Cruciate (PCL) – prevents tibia from slipping backward over femur posteriorly. Not palpable. Knee menisci
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Medial and Lateral
Cushion between the femur and tibia
Valgus or Varus test
Pain or gap medial joint line indicates ligament tear or laxity. Medial injury is the most common
Valgus test
Varus Test
 abduction valgus stress for medial meniscus tear
 Supine, knee slight flexion, thigh out 30 degrees laterally. Hand against knee for femur stability, other hand around ankle – abduct by pushing medial (IN) at knee and pulling laterally at ankle to stress or open medial knee joint looking for gap or pain
 Adduction for lateral meniscus tear
 Supine, knee slight flexion, thigh out 30 degrees. Hand to stabilize medial knee and hand on medial ankle, push or hold medially against knee and pull ankle medial to open lateral side of joint, looking for pain or gap
Knee bursa
Knee Bursas
 Suprapatellar
 Prepatella – between patella and overlying skin
 Anserine – medial surface of knee, 1‐2 inches below joint
 Semimenbranosus – large, communicates with knee joint cavity posteriorly
Knee Ligaments
Diagnostic Tests for knee ligaments
 Drawer test:  Anterior sign ‐ ACL
 Posterior sign – PCL
 Hip and knees flexed 90 degrees, feet flat on table. Thumbs on medial and lateral joint line, pull tibia forward – if tibia slides ‐‐ shows ACL tear. Push tibia back and watch degree of femur backward movement for PCL tear (rare)
Tests for knee ligaments
 Lachman test – ACL – 15 flex and external rotation. Hold one hand on distal femur and one on upper tibia—thumb on tibial joint line and move tibia forward, femur back. Significant forward movement = ACL tear
 McMurray test – meniscus tear with click felt or heard during knee flexion/extension (posterior) external rotation/leg extension (medial)
Differential Diagnosis
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Further diagnostic help
 X‐ray
 MRI
 Ultrasound?
Joint pain
Bursa pain
Muscle Tendon
Ligament
Treatment plan
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Pain relief: OA, RA, arthritis, acute injury
RICE
PT
Speciality Referral
NO injections without proper indications
References
 Bickley, L. Bates’ Guide to Physical Examination and history taking. 9thed. Lippincott, Williams & Wilkins; Philadelphia. 2009.
 Buttaro, T, Trybulski, J, Bailey, P and Sandberg‐Cook, J. Primary Care. A Collaborative Practice. 3rd Edition. Mosby Elsevier; St. Louis, MO. 2008.  Waldman, S. Physical Diagnosis of Pain. An Atlas of Signs and Symptoms. 1st edition. Elsevier Saunders; Philadelphia, PA. 2006.
Hands on!
 Pick a partner