Download PHYSICAL EXAM SKILLS

ROTATION HANDOUT
FAMILY MEDICINE RESIDENTS
ORTHOPEDICS ROTATION
Gaetano P. Monteleone, Jr., M.D.
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
PHYSICAL EXAM SKILLS
Consider Magee’s Orthopedic Physical Assessment and Hoppenfeld’s Examination of the Spine
and Extremities for further exam techniques in orthopedic medicine.
I.
•
•
ANKLE
Range of Motion (ROM)
Dorsiflexion (0-20°)
Anterior tibialis, Toe extensors (hallucis longus, digitorum longus).
Plantar flexion (0-50°)
Gastroc/soleus unit, Posterior tibialis, Toe flexors (hallucis longus
and digitorum longus).
Inversion (0-35°)
Anterior tibialis
Eversion (0-15°)
Peroneus longus and brevis
Special Tests
1. Anterior Drawer- measure
translation (in mm)
ROTATION HANDOUT
FAMILY MEDICINE RESIDENTS
ORTHOPEDICS ROTATION
Gaetano P. Monteleone, Jr., M.D.
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
2. Talar Tilt- measure opening (in degrees)
3. Side-to-side (Cotton test)- especially for syndesmosis sprains
•
Side-to-side (Cotton) test- place examining hand under the plantar aspect of the foot/ankle,
with your thumb under one malleolus and your
middle finger under the other malleolus. Place a
medial
and
lateral-directed
force
(not
inversion/eversion stress as in the talar tilt test) on
the ankle. Assess if translation and assess quality of
endpoint. There may be a few mm of motion with a
syndesmosis sprain. An alternative to this is to
passively externally rotate the foot. Pain with this
maneuver will occur in a syndesmosis sprain.
4. Proximal squeeze test- also for syndesmosis sprains
•
Proximal squeeze test- examiner squeezes mid-shaft of tibia/fibula. Pain in the
syndesmosis area may indicate a syndesmosis sprain.
5. Neurovascular
Compare to unaffected ankle!
II.
KNEE
•
Inspection- deformity, effusion, ecchymoses, erythema, Q angle, muscle asymmetry
(atrophy).
•
Palpation
a. Anterior- patella, patellar tendon, quadriceps tendon, joint line, tibial tubercle.
b. Medial- patellar retinaculum, MCL (origin and insertion), meniscus, pes
anserine tendons, pes anserine bursa, medial femoral condyle, medial facet of the
patella.
c. Lateral- patellar retinaculum, LCL, lateral meniscus, iliotibial band (inserts at
Gerdy's tubercle), lateral femoral condyle.
d. Posterior- hamstring tendons, posterior joint line (posterior horns of the
meniscus, popliteal fossa (neurovascular structures, Baker's cyst).
e. Joint line tenderness- posterior joint line tenderness more sensitive for
meniscal injury than anterior. Anterior joint line tenderness may reflect anterior
knee pain syndromes, osteochondritis dessicans, etc. In addition, joint line
tenderness is most sensitive if not associated with an ACL tear.
N.B. When palpating joint line, internal tibial rotation renders the lateral meniscus more
palpable, external tibial rotation renders the medial meniscus more palpable.
•
•
ROM/Flexibility- include hamstring flexibility. Decreased ROM (especially extension)
may represent a tear that flips up and blocks full extension, AKA "locked knee."Tight
hamstrings must be assessed.
Special Tests for Patellofemoral problems
a. Patellar apprehension test- patient supine:
examiner provides lateral distraction to the
patella; positive test is apprehension that the
patella will dislocate.
b. Patellar grind/compression tests- patient
supine: active, isometric contraction of the quads
by patient with posteriorly directed force placed
on the patella by examiner. Positive test is
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reproduction of the patients pain with this maneuver.
c. Q (quadriceps) angle- measure of genu valgus (knock-kneed). The angle
created by two lines: one drawn from the middle of the patella and the tibial
tubercle, and the other line from the middle of the patella and the ASIS of the
iliac crest. Normal in males is < 10° , females < 15°. Patients with high Q angles
are at increased risk for patellofemoral conditions.
d. "J" sign- patient in seated position: patient
slowly extends knee to 0°. Normally, examiner
observes the patella gliding proximally with
extension. A positive J sign is observed when as
the knee approaches full extension, the patella will
not only glide proximally, but will lateralize in the
final degrees of extension (inverted "J"). Patients
with malalignment or poor biomechanics will
demonstrate a positive J sign. May indicate
instability.
•
Special Tests for Ligamentous
abnormalities
Grading system for most ligament sprains/tears:
Grade
Histology/Translation
1
Fibers stretched, no laxity
2
Few fibers torn, some laxity
3
Many fibers torn, much laxity
Endpoint
Good
Fair
Poor, soft
a. Valgus/varus stress tests @ 0° and 30° of flexion: tests MCL/LCL,
respectively. Instability during valgus stress with the knee in complete extension
demonstrates both and MCL and ACL tears.
b. Lachman's test for ACL. Knee in 30°of flexion. Outside hand stabilizes the
femur, inside hand around the tibia at the tibial tubercle.
An anteriorly-directed force is applied. Assess for
translation (in mm) and endpoint (good, fair, poor). This
is the most accurate exam maneuver for ACL tears
acutely. False negative tests occur when hamstring
spasm with tense effusion, bucket-handle tears of
meniscus. False positive test with PCL tear.
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c. Anterior/posterior drawer tests- for ACL and PCL, respectively. The knee is
flexed to 90°, hip at 45° with feet flat on exam table; examiner may sit on foot,
apply an anteriorly or posteriorly-directed force. Maintain thumbs at joint line.
Assess for translation and quality of endpoint. The a nterior drawer is generally
not as helpful as the Lachman and pivot shift tests for ACL integrity. In addition,
it requires more motion to an acutely injured knee. The posterior drawer test, on
the other hand, is the most helpful test for PCL integrity.
d. Pivot shift test- for ACL integrity. Start with knee straight and an examining
hand under heel of foot. Turn the foot into internal rotation with one hand, place a
valgus-directed force at the knee with the other hand. At the same time, bring the
knee from extension to flexion. A palpable clunk appreciated at 30° of flexion at
the joint line represents the tibia reducing on the femur in ACL-deficient knee.
This may be quite uncomfortable for the acutely injured patient. It requires
significant relaxation on the part of the patient, and they probably won't let you do
it a second time (so get it right the first time!). This is the most accurate test for
chronic tear of the ACL (> 6 months).
e. Posterior sag sign- have patient lying relaxed and supine, with knees in
position similar to the anterior/posterior drawer tests. In
patients with a PCL tear, the tibial tubercle will sag
posteriorly relative to the other tibial tuberosity. The
quadriceps active test- for PCL integrity involves the
same position. Active contraction of the quadriceps will
shift the tibial tubercle anteriorly (back to neutral) in a
patient with a PCL tear. Figure at right describes the
posterior sag and the quadriceps active tests.
f. Apley's distraction test- patient lying prone, knee
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flexed to 90°, examiner stabilizes posterior femur in one hand and distracts the
foot upward. At the same time, the foot should be rotated internally and
externally. Reproduction of patients pain may indicate MCL/LCL sprain or tear.
A variation to this is Apley's compression test. Performed similarly to the
distraction test, the examiner produces a compression force from the heel directed
into the exam table. Again, reproduction of pain with internal/external rotation of
the foot is a positive test. This may indicate possible meniscal pathology.
Note: in patients with open growth plates, positive Lachman's test, valgus/varus tests may
actually represent opening of tibial or femoral growth plate fracture.
•
Special tests for Meniscal tears
a. McMurray test- positive test indicated by a palpable or audible clunk. Pain is
not diagnostic. This test performed by palpating bilateral joint lines with the pt
supine. The examiner produces internal/external tibial rotation while flexing and
extending the knee. Simultaneously, the examiner produces a valgus or varusdirected force.
The value of this and other clinical exam tests for the meniscus has been questioned. The
positive predictive value approximates 85%, for audible/palpable click. The positive predictive
value is higher in the medial meniscus and lower for the lateral meniscus.
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b. Apley's compression test positive for pain. Pt prone. Knee flexed to 90°. The
examiner produces a compression force directed toward the exam table. Note
distraction stress may stretch the collateral ligaments and create pain. This may
distinguish MCL vs medial meniscus injury.
III.
HIP
Physical Exam
•
Inspection- deformity, ecchymoses, erythema, muscle asymmetry (atrophy).
•
Palpation- Anteriorly palpate the ASIS, AIIS, pubic symphysis, neurovascular structures
(femoral artery, vein and nerve), musculature; Laterally palpate the iliac crest, greater
trochanteric bursa; posteriorly palpate the PSIS, gluteal muscles, greater sciatic notch,
ischial tuberosity and bursa, SI joint, L-spine.
•
Range of Motion (ROM)- flexion (0-120°), extension (0-30°), abduction (0-45°),
adduction (0-30°), external rotation (0-50°), internal rotation (0-40o)
•
Special testsa. FABER test (Flexion, ABduction, External Rotation at the hip)- Pt places leg in
figure of four position. Place the examining ankle on the contralateral knee and relax the
knee out with external rotation of the hip. Tests for hip muscle flexibility, SI joint
pathology.
b. Trendelenberg sign- have pt stand on affected leg. Normal and negative test is an
inclination of the contralateral PSIS. An abnormal (positive) test results in a drooping of
the contralateral PSIS. May indicate gluteus medius weakness.
c. Ortolani’s and Barlow’s hip clunk for developmental dislocation of the hip (DDH).
Ortolani’s opening of the hips (abduction/external rotation) reduces a dislocated hip;
Barlow’s closure of the hips (adduction/internal rotation) dislocates the hip again. These
tests are best performed during the first few weeks of life. After that, false negative tests
can occur due to muscular spasm, etc.
d. Limb length discrepancy- measure ASIS to medial malleolus in cm. Compare both
sides. Some discrepancy is normal. Correct for more than 1.0-1.5 cm. Most (90%)
discrepancies due to soft tissue tightness, inflexibility rather than actual difference in
bone length.
e. Neurovascular assessment-. Femoral artery, nerve; nerve roots L1-S1.
f. L-spine exam- a good hip exam includes an L-spine exam as well.
IV.
BACK
Physical Exam
•
Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking
•
Palpation- point tenderness (bony and soft tissue)
•
Range of Motion- measure forward flexion in inches from the floor
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N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion
are important. However, they have low diagnostic utility, since many causes of acute low
back pain will manifest these signs.
•
Neurovascular Assessment (most important is L4-S1): individually test heel and toe
walking. Minor asymmetry is common. A positive test should show marked asymmetry.
Nerve Root
Sensory
Reflex
Motor
L4
Anterolateral thigh
Medial ankle
Patellar
Tibialis anterior
L5
Posterolateral thigh
Dorsum of ankle
? Posterior tibialis
Extensor hallucis
longus
S1
Lateral ankle
Achilles
Peroneus
Cross innervation is common and may result in misinterpretation. For screening
purposes, extensor hallucis longus (L5) is most important. Remember that differentiating a
peripheral nerve abnormality is necessary. Posterior tibialis and gluteus medius muscles are
innervated by L5 nerve root, but not the peripheral peroneal nerve. Note, these tests have only
moderate sensitivity and specificity for nerve root irritation.
•
Special Tests
a. Straight leg raise (SLR) + ankle dorsiflexion: pt supine, raise leg to 30-60°; + test is
pain that radiates into the calf. Also, crossed SLR = SLR in unaffected limb exacerbates
radicular pain in affected limb.
b. Modified SLR (? Lasegue's test): hip flexed to 90°, knee flexed to 90°, this should
not cause pain if HNP; examiner then extends the knee until nerve root is stretched. Pain
with knee extension may indicate nerve root irritation demonstrated with HNP or
impingement with OA.
c. Bowstring sign: SLR until pain, then flex the knee. This should reduce/extinguish pain
if nerve root irritation.
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d. Seated straight leg raise: With pt seated, examiner passively extends the knee; + test
produces radicular pain.
e. FABER test = Flexion ABduction External Rotation of the hip: this position posterior
may cause pain in SI joint pathology.
f. One-leg extension (or Arabesque) test: pt stands on one leg with back in extension
(examiner supports); + test of pain may indicate spondylolysis.
g. Hamstring flexibility- pt supine, hip and knees both at 90° flexion; examiner attempts
to passively straighten leg.
h. Leg length evaluation- measure from ASIS to medial malleolus (in cm).
V.
SHOULDER
The physical exam will confirm or eliminate diagnostic possibilities suggested by the
history. Each clinician should develop a systematic approach to their examination. The various
components include the following. The various tests can be focused depending on the presenting
history.
•
Range of motion- abduction, forward flexion, internal and external rotation. Compare
with unaffected side. Remember that in repetitive overhand athletes, external rotation is
increased and internal rotation is slightly decreased in the throwing shoulder.
•
Strength- test deltoid, supraspinatus, internal (subscap) and
external (infraspinatus) rotators against manual resistance and
compare with opposite side. While you are testing strength,
also see if the specific maneuver causes pain which will indicate
tendinitis. Once tendinitis is
demonstrated, the key is to ask
why- impingement and
instability are two common causes of tendinitis. If
indicated, manual muscle testing is carried out on other
muscle groups including trapezius, rhomboids, serratus,
latissimus, and pectoralis.
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•
Palpation- systematic palpation of bones and joints (SC joint, AC joint, clavicle,
acromion, scapula, greater tuberosity of humerus). Palpation of muscles groups of the
shoulder. Direct palpation of the insertion of the supraspinatus is best achieved by
palpating the anterior shoulder with the humerus in slights extension.
•
Special testsa.
Cross chest (hyperadduction) test- for
AC joint pathology. Affected hand to
contralateral shoulder. Pain at AC joint
diagnostic.
b.
Neer's sign (forward
flexion/internal rotation) for
subacromial impingement.
c.
Hawkin's sign (90° abduction and 45° of horizontal adduction, then
humeral internal rotation) for sub- acromial impingement.
d.
Apprehension test (sitting position)- Pt is lying supine with humerus
abducted to 90o and externally rotated to 90o. Apprehension test produces
apprehension that shoulder will come out of joint. Tests for underlying
instability.
Yergason's test- resisted forearm supination testing biceps tendon pain.
Speed's test (for biceps tendinitis)- performed with elbow extended,
forearm supinated, and forward elevation of the humerus to approximately
60° with manual resistance. Pain recreated in bicipital groove constitutes
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e.
f.
Ortho Rotation Handout Revised 11.4.04
g.
h.
positive test for biceps tendon pain.
Relocation test (Jobe)- with the patient in the same position as in d. The
Jobe relocation test, position patient as in apprehension test, then grasp
proximal humerus and apply anterior displacement followed by posterior
displacement. Pain with anterior displacement followed by relief of pain
with posterior displacement constitutes a positive test for anterior
instability.
Modified "Lachman's" of the shoulder- with patient in supine position,
examiner places one hand behind proximal humerus while gently grasping
the humerus at the bicondylar axis at the elbow. Patient's humerus is
abducted approximately 120°. With the elbow held steady the examiner
gently translocates the humeral head anteriorly, evaluating for amount of
excursion and quality of end point. Shoulder with anterior instability may
show increase in laxity and difference in end point quality compared to
unaffected side. Patient must be completely relaxed.
i.
Sulcus sign- with patient seated and arm held
relaxed at side, examiner grasps lower humerus
and applies an inferior force. Space or 'sulcus'
may appear depending on amount of inferior
instability. Compare with opposite arm.
j.
Labral "clunk" test- same position as the test
in 'h'. The examining hand behind the humeral
head palpates for a "clunk" as the other hand
moves the humerus in a rotary motion, in effect
trying to trap the labral tear between the
humeral head and glenoid. This is analogous to the McMurray's test for
meniscal tears of the knee.
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Quick Guide to Neurologic Status to the Extremities
UPPER EXTREMITY
Root
Reflex
C5
Biceps
C6
Brachioradialis
C7
Triceps
C8
T1
Motor
Sensory
Deltoid, Biceps
Lateral Arm
Wrist Extension, Biceps
Lateral Forearm,
Thumb/index finger
Wrist Flexion, Triceps
Middle finger
----
Interossei, Finger
Flexion
Medial Forearm,
Ring/pinky finger
----
Interossei
Medial Arm
Peripheral nerve
Motor
Sensory
Radial nerve
Wrist Extension
Ulnar nerve
Abduction pinky
Distal ulnar pinky
Median nerve
Thumb: pinch, opposition, and
abduction
Distal radial index
Axillary nerve
Musculocutaneous nerve
Dorsal thumb/index web space
Deltoid
Lateral Arm
Biceps
Lateral Forearm
LOWER EXTREMITY
Root
Reflex
Motor
Sensory
L4
Patellar
Anterior Tibialis
L5
None-? Post Tibialis
Ext Hallucis Longus
Lateral Leg,
Dorsum Foot
S1
Achilles
Peroneus L & Br
Lateral Foot
Ortho Rotation Handout Revised 11.4.04
Medial Leg & Foot
12
Muscle Action and Innervation
Upper Extremity
Note: Range of motion= AAOS; innerv= Hoppenfeld's
I.
Shoulder
A. Abduction (0-180°)
1°
· supraspinatus (C5-6) suprascapular n.
· mid deltoid (C5-6) axillary n.
2°
· ant & post deltoid
· serratus anterior
1°
2°
1°
2°
1°
2°
1°
2°
1°
2°
B. Adduction
· pectoralis major (C5-T1) med & lat anterior thoracic n.
· latissimus dorsi (C6-8) thoracodorsal n.
· teres major
· ant deltoid
C. Flexion (0-180°)
· ant deltoid (C5) axillary n.
· coracobrachialis (C5-6) musculocutaneous n.
· pectoralis major (clavicular head)
· biceps
· ant deltoid
D. Extension (0-60°)
· latissimus dorsi (C6-8) thoracodorsal n.
· teres major (C5-6) lower subscapular n.
· post deltoid (C5-6) axillary n.
· teres minor
· triceps (long head)
E. Internal (medial) rotation (0-70°)
· subscapularis (C5-6) upper & lower subscapular nn.
· pectoralis major (C5-T1) med & lat anterior thoracic n.
· latissimus dorsi (C6-8) thoracodorsal n.
· teres major (C5-6) lower subscapular n.
· ant deltoid
F. External (lateral) rotation (0-90°)
· infraspinatus (C5-6) suprascapular n.
· teres minor (C5) br of axillary n.
· post deltoid
G. Scapular elevation
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1°
1°
· trapezius CN XI
· levator scapulae (C3-4)
· rhomboids
H. Scapular Protraction
· serratus anterior (C5-7) long thoracic n.
1°
I. Scapular Retraction
· rhomboids (C5) dorsal scapular n.
2°
II.
1°
2°
1°
2°
Elbow
A. Flexion (0-150°)
· biceps (C5-6) musculocutaneous n.
· brachialis (C5-6) musculocutaneous n.
· brachioradialis
· supinator
B. Extension
· triceps (C7) radial n.
· anconeus
1°
C. Supination
· biceps (C5-6) musculocutaneous n.
· supinator (C6) radial n.
1°
D. Pronation
· pronator teres (C6) median n.
· pronator quadratus (C8-T1) anterior interosseous n.
III.
1°
1°
Wrist
A. Flexion (0-80°)
· flexor carpi radialis, FCR (C7) median n.
· flexor carpi ulnaris, FCU (C8) ulnar n.
B. Extension (0-70°)
· extensor carpi radialis longus, ECRL (C6) radial n.
· extensor carpi radialis brevis, ECRB (C6) radial n.
· extensor carpi ulnaris, ECU (C7) radial n.
Lower Extremity
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I.
1°
2°
Hip
A. Abduction (0-45°)
· gluteus medius (L5) superior gluteal n.
· gluteus minimus
1°
2°
B. Adduction (0-30°)
· adductor longus (L2-4) obturator n.
· adductor brevis & magnus
C. Flexion (0-120°)
· Iliopsoas (L1-3) femoral n.
· Rectus femoris
1°
2°
D. Extension (0-30°)
· gluteus maximus (S1) inferior gluteal n.
· hamstrings
1°
2°
2°
E. External Rotation (0-50°)
· gluteus maximus (L5-S 2) inferior gluteal n.
· obturator m (L3-S1) obturator n.
· piriformis
1°
2°
F. Internal Rotation
· adductors (L2-4) obturator n.
· gluteus medius and minimus
1°
II.
1°
1°
III.
1°
1°
2°
Knee
A. Flexion (0-135°)
· semimembranosus (L5) tibial n.
· semitendinosus (L5) tibial n. } Hamstrings
· biceps femoris (S1) tibial n.
B. Extension
· quadriceps (L2-4) femoral n.
Ankle
A. Dorsiflexion (0-20°)
· tibialis anterior (L4) deep peroneal n.
· extensor hallucis longus (L5) deep peroneal n.
· extensor digitorum longus (L5) deep peroneal n.
B. Plantar flexion (0-50°)
· gastroc/soleus (S1-2) tibial n.
· peroneus longus & brevis (S1) superficial peroneal n.
· flexor hallucis longus
· flexor digitorum longus } (L5) tibial n.
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· tibialis posterior
1°
C. Inversion (0-35°)
· tibialis anterior (L4) deep peroneal n.
1°
D. Eversion (0-15°)
· peroneus longus & brevis (S1) superficial peroneal n.
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Common Xrays Ordered in the Sports Medicine Clinics
Ankle
AP
Lateral
Mortise (20° internal rotation)
C-spine
AP
Lateral
Obliques X 2
? Trauma
Open mouth (Fuchs) view
Lateral flexion/extension views (must be done at NCBH)
Elbow
AP
Lateral
Optional = radial head view, obliques X 2
Foot
AP
Lateral
Oblique
Forearm
PA
Lateral
Oblique
Hand
PA
Lateral
Optional = oblique
Hip
AP pelvis
Lateral of L-spine
Frog leg lateral
Knee
AP Weightbearing (if ? DJD)
Lateral
Merchant (or other tangential view: ie- sunrise)
Tunnel /notch (? OCD)
Leg
AP tibia/fibula
Lateral tibia/fibula
Optional = oblique tibia/fibula
L-spine
AP
Lateral
Obliques X 2
Shoulder
Trauma
Standing AP and lateral if ? listhesis
AP with IR/ER
Axillary lateral (West Point) view
Scapulolateral "Y" view
Impingement AP with IR/ER
Axillary lateral
Supraspinatus outlet (Alexander) view
Wrist
Instability
include True AP
AC joint
AP with caudal tilt (15°)
PA
Lateral
Oblique
Optional = scaphoid view (AP with ulnar deviation) and
carpal tunnel view
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