Mastering the MSK Exam and Procedures in · PDF fileOffice Procedures in Orthopaedics ... Knee Anatomy. The quadriceps ... who had joint aspirated at time of injection in knee OA

Mastering the MSK Exam andOffice Procedures in Orthopaedics

UCSF Essentials of Women’s HealthJuly 9, 2015

Carlin Senter, M.D.

I have nothing to disclose

Outline

• Knee exam

• Knee aspiration and injection

• Shoulder exam

• Subacromial bursa injection

Knee Anatomy

The quadriceps muscles extend the

knee

http://thefitcoach.wordpress.com/2012/04/07/267/http://scientia.wikispaces.com/Thigh+and+Leg+‐+Lecture+Notes

The quadriceps muscles merge to form the quadriceps tendon… patellar tendon

The hamstrings flex the knee

www.hep2go.com

Pes anserine bursa

http://meded.ucsd.edu/clinicalmed/joints.htm

There are 4 main ligaments in the knee

Meniscus

Knee exam

Musculoskeletal work‐up

•History

• Inspection•Palpation

•Range of motion

•Other Tests

Common Causes of Knee Pain by Location of Symptoms

• Anterior:

- Patellofemoral syndrome

- Quadriceps tendinitis

- Patellar tendinitis

• Lateral:

- Lateral jointline: meniscus tear or OA

- IT band syndrome

- LCL sprain (rare)

- Fibular head: fracture (rare)

• Medial- Medial joint-line: meniscus tear or OA

- MCL sprain- Pes anserine bursitis

• Posterior

- Hamstring tendinitis

- Gastrocnemius strain

- OA, meniscus tears,effusion, popliteal cyst….

Inspection

http://doctorhoang.wordpress.com/2010/09/06/valgus‐knee‐and‐bunion/

http://meded.ucsd.edu/clinicalmed/joints.htm

Palpation of joint lineseated or supine

http://www.rheumors.com/kneeexam/palpation.html

Palpation of patella - supine

Ballottement

Palpation of patellar facet

Knee range of motion

• ROM: normal 0‐135

– Determine if knee is locking or if ROM is limited due to effusion

– Locking: think bucket handle meniscus.• Urgent xrays, MRI

• Urgent referral to sports surgeon for arthroscopy

Permission for use provided by Dr. Charles Goldberg, UCSD

Other Tests: Lachman to evaluate ACLSensitivity 75‐100% Specificity 95‐100%

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

PCL: Posterior Drawer

MCL and LCL

MCL and LCL grading

Grade Injury Translation compared to unaffected

side

Patient response

I Strain Minimal laxity, firm endpoint

Pain

II Partial tear Some laxity, firm endpoint

Pain, may feel loose

III Complete tear Obvious laxity,no endpoint

Minimal pain, may feel very

loose

4 tests for meniscus tear

1. Isolated joint line tenderness

2. McMurray

3. Thessaly

4. Squat

These tests not needed in patients with knee OA.

Do these tests in patients < 50 with isolated joint line tenderness.

Meniscus: McMurray

Sensitivity medial 65%, Specificity medial 93%Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

Meniscus: Thessaly

Meniscus: Squat

Knee exam practice

• Standing: inspection– Varus or valgus

• Sitting: palpation– Joint line

– Femoral condyles

– Tibial plateau

– Fibular head

• Supine– Patellar facets

– Patellar grind

– ROM

– Special tests• Lachman

• Posterior drawer

• Varus 0 and 30

• Valgus 0 and 30

• McMurray medial and lateral

• Thessaly

• Squat

Knee aspiration and injection

Intra‐articular corticosteroid injections: do they work for knee OA?

• Good short‐term pain relief (6 weeks average)• No significant effect on function• No evidence for long‐term pain relief• Clinical effect independent of degree of inflammation

present – Don’t need to restrict injection just to those with effusion

• Frequency: general practice once every 3 months max– Concern for cartilage toxicity with more than 4/year

• AAOS: recommends for short‐term pain relief (level II)• ACR: Conditional recommendation (per 2012 guidelines)

Zhang W et al. OARSI recommendations for the management of hip and knee osteoarthritis: Osteoarthritis Cartilage. 2010 Apr;18(4):476‐99.

Superolateral approach

• Patient supine

• Extend knee

• Bump under knee so flexed 10‐20 degrees

• Superior border patella

• Lateral border patella

• 1cm below

• Mark with syringe cover or tip of pen

Injection set‐up bucket

• Betadine

• Ethyl chloride

• Alcohol swabs

• 4x4 guaze

• Bandaids

Injection prep

Needles, syringes, meds

Corticosteroids

Why use local anesthetic with steroid injection?

• Dilute the steroid– Decrease likelihood of steroid atrophy

– Decrease irritant nature of steroid crystals causing post‐injection flare

• Pain relief– Diagnostic and therapeutic (subacromial more than knee)

• Floculation: combining steroid and local anesthetic can precipitate crystals. Carefully inspect for precipitate before injection.

Aspiration

Why aspirate the effusion before injection?

• Clinically– Decreased pain and stiffness because effusion gone

– More effect of steroid because not diluted by effusion

– Inspect fluid for inflammation/infection, send to lab if question

– Confirms that injxn was intra‐articular

• Significantly greater improvement in VAS for patients who had joint aspirated at time of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.)

• Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.)

Post‐injection patient instructions

• Rest: no definitive evidence‐based recommendation

– Recommendations in literature vary

• No restrictions

• Bed rest x 24 hours

• Light activity x 7 days, no weight bearing exercise

• Avoid swimming, hot tub, bath x 24 hours

– Let injection site heal

Contraindications to steroid injection

• Joint infection

• Fracture

• Prosthetic joint

• Hemarthrosis (theoretically higher risk of infection)

• Soft tissue infection overlying joint

Relative contraindications to steroid injection

• Corticosteroid injection within past 4 months

• Coagulopathy (ok if on warfarin but check recent INR, make sure not >> 3)

• Poorly controlled diabetes

Risks of steroid injection in the knee

• Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days

• Suppression of hypothalamic pituitary adrenal axis, mild– Lasts 1‐3 days post‐injection

• Facial flushing: 10% with Kenalog– 19‐36 hours post‐injection

• Skin or fat atrophy• Post‐injection steroid flare: 1‐10%

– Synovitis in response to injected crystals– Within hours ‐ 48 hours post‐injection– More common in soft tissue injections (20% of trigger points) than intra‐

articular injections

• Septic arthritis: 1/3000‐1/50,000– 1‐2 days after injection

• Possible risk of chondrocyte toxicity with repeated injections

Habib GS. Clin Rheumatol, 2009.UpToDate, “Joint aspiration or injection in adults,” 2010.

My current knee injection steps

1. Patient supine with bump under knee2. Mark injection site (superior lateral)3. Betadine x 34. Alcohol x 15. Ethyl chloride for skin anesthesia6. Alcohol again7. 22g needle attached to 10cc syringe containing 5cc of 1%

lidocaine without epi8. Slowly advance and inject lidocaine, 1mm at a time9. Feel resistance give when in joint10. Aspirate, make sure fluid straw‐colored and clear11. Keep needle in place, switch syringe 12. Inject 1cc of 40mg kenalog

Knee injection

Shoulder anatomy

Underlying Anatomy ‐ Bones

• Humerus• Scapula

o Glenoido Acromiono Coracoido Scapular body

• Clavicle• Sternum Glenohumeral

Joint

Clavicle

Lesser Tuberosity

Greater Tuberosity

Acromion

The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa

Spine ofscapula isat the levelof T3

Bottom of scapula is at level of T7

Acromion

The tendons of the rotator cuffmuscles reinforce the capsule of the glenohumeraljoint.

Subscapularis(Internal Rotation)

Anterior View

The Rotator Cuff Muscles (SITS)

Lesser Tuberosity

Infraspinatus(External rotation))

Teres Minor(External rotation)

Supraspinatus (Abduction)

Posterior View

Greater Tubersosity

The Biceps Muscle

• #1 Supination of the elbow (screwing, twisting)

• #2 Flexion of the elbow

3 attachments:

• Radial tuberosity (distal)

• Glenoid (long head)

• Coracoid (short head)

Long head

Short head

Shoulder exam

Shoulder examination

Special Tests:

• Spurling’s (cervical spine radiculopathy)• Hawkins impingement sign• Neers impingement sign• Painful arc (rotator cuff dz)• Jobe’s, aka Empty‐can (supraspinatus)• Drop arm test (rotator cuff dz)• Resisted external rotation (infraspinatus)• External rotation lag test (rotator cuff tear)• Belly press test (subscapularis)• Lift‐off test (subscapularis, rotator cuff tear)• Speeds (biceps)• Yergason’s (biceps)• O’briens (SLAP tear)• AC crossover (AC joint OA or sprain)

Key Components of the Shoulder Exam:‐ Neck‐ Shoulder‐ Inspection‐ Palpation ‐ Range of Motion: abduction, flexion, ER, IR‐ Strength‐ Neurovascular

Shoulder

http://meded.ucsd.edu/clinicalmed/shoulder_exam.htm

Neck examination

• Inspection

• Palpate CS

• FF and extension

• Spurlings

Cervical SpineSpurling’s Maneuver

• Neck extended• Head rotated toward

affected shoulder• Axial load placed on

the cervical spine• Reproduction of

patient’s shoulder/arm pain indicates possible nerve root compression


• Inspection– Patient in gown

• Palpation

• ROM

• Strength– Supra

– Infra and teresminor

– Subscapularis

• Other tests http://meded.ucsd.edu/clinicalmed/joints2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

Inspection

• Presence of infraspinatus atrophy increases likelihood of rotator cuff disease

• Positive LR 2.0

• Negative LR 0.61

Litaker D et al, J Am Geriatr Soc, 2000.


• Inspection

• Palpation• ROM

• Strength– Supraspinatus

– Infraspinatus & Teres minor

– Subscapularis

• Other tests

http://meded.ucsd.edu/clinicalmed/joints2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

Range of motion

Abduction

Flexion

Range of motion

External rotation

Internal rotation

Supine shoulder PROM

Passive range of motion

• If limited AROM in any direction

• Follow up by testing passive motion in that direction

• If limited active and passive ROM think

– Frozen shoulder

– Glenohumeral joint arthritis

Shoulder exam practice

• Neck: palpation, ROM and Spurling’s maneuver

• Inspection

• Palpation

• AROM– Abduction

– Flexion

– External rotation (ER)

– Internal rotation (IR)

• PROM 1

Shoulder: diagnosis driven exam

Active ROM

DecreasedNormal

Passive ROM

Normal

Decreased

Xray

Frozen shoulder Normal

GH joint OA

Abnormal

Weak = Rotator cuff tear

Limited by pain = Other rotator cuff dz

Labral tearBiceps tendinitis

AC joint OA

Other tests

• Rotator cuff disease (RCD)

– Bursitis or impingement

– Tendinitis/tendinopathy

– Partial tear

– Full thickness tear

• Biceps tendinitis/tendinopathy

• Labral tear

• AC joint osteoarthritis

What’s the best way for PCPs to examine the shoulder for RCD?

We concluded that there is insufficient evidence upon which to base selection of physical tests for shoulder impingement, and potentially related conditions, in primary care.

Rotator cuff disease exam

• Pain provocation tests • Pain and strength tests• Often the pain radiates to lateral shoulder/proximal arm (“deltoid”)

Pain test: Painful arc

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

If painful, positive LR 3.7 for RCD.If not painful, negative LR 0.36 for RCD.

Pain test: Impingement signs

Hawkin’s

Neer’sPhotos from Dr. Christina Allen

Exam practice:pain provocation tests in RCD

• Hawkins impingement sign

• Neers impingement sign

• Painful arc (rotator cuff dz)

2

Pain & Strength test: Supraspinatus = abduction

Empty can(aka Jobe’s)

Photos from Dr. Christina Allen

Supraspinatus

71% sensitivity41% specificity for rotator cuff disease. (+) LR 1.3

Pain/strength test: Drop arm test


Positive LR 3.3, negative LR 0.82 for rotator cuff disease.

Physical exam maneuvers that increase likelihood of

full thickness rotator cuff tear

1. External rotation lag test

2. Internal rotation lag test

https://www.healthbase.com/hb/images/cm/procedures/orthopedics/rotator_cuff_tear.jpg

Strength test:External rotation lag test

Positive LR 7.2,Negative LR 0.57 for full thickness rotator cuff tear


Pain & Strength test:Subscapularis = internal rotation lag test


Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear

Exam practice:Rotator cuff strength and tear

• Jobe’s, aka Empty‐can (rotator cuff disease)

• Drop arm (rotator cuff disease)

• External rotation lag test (rotator cuff tear)

• Internal rotation lag test aka Lift‐off test (rotator cuff tear)

3

Biceps Tests: Speeds

Tests for biceps pathology (tendinitis, tendinopathy, tear)

Palms up, patient pushes up against resistance (resisted elbow flexion)

+Test is pain at proximal biceps tendon

Sens = 54%, Spec = 81%

Biceps Tests: Yergasons

Tests for biceps pathology (tendinitis, tendinopathy, tear)

Patient supinates (twists out) against resistance

+Test is pain at proximal biceps tendonAlso tests for biceps strength

Sens = 41%, Spec = 79%

O’Brien’s TestTo r/o Labral Tear

• Arm forward flexed to 90°

• Elbow fully extended• Arm adducted 10° to

15° with thumb down• Downward pressure• Repeat with thumb up• Suggestive of labral tear

if more pain with thumb down

• Sens = 59-94%, • Spec = 28-92%

Testing the AC Joint: AC Crossover

• Tests for AC joint osteoarthritis or sprain

• Can be done passively by patient or physician

• +Test is pain at AC joint

Exam practice:biceps tendinitis, labral tear, AC OA

• Speeds (biceps)

• Yergason’s (biceps)

• O’briens (SLAP tear)

• AC crossover (AC joint OA or sprain)

4

Simon says:put it all together

Special Tests:

• Spurling’s (cervical spine radiculopathy)• Hawkins impingement sign• Neers impingement sign• Painful arc (rotator cuff dz)• Jobe’s, aka Empty‐can (supraspinatus)• Drop arm test (rotator cuff dz)• Resisted external rotation (infraspinatus)• External rotation lag test (rotator cuff tear)• Belly press (subscapularis)• Lift‐off test (subscapularis, rotator cuff tear)• Speeds (biceps)• Yergason’s (biceps)• O’briens (SLAP tear)• AC crossover (AC joint OA or sprain)

Key Components of the Shoulder Exam:

‐ Inspection‐ Palpation ‐ Range of Motion: abduction, flexion, ER, IR‐ Strength‐ Neurovascular‐ Special tests

Shoulder

http://meded.ucsd.edu/clinicalmed/shoulder_exam.htm

Subacromial injection for impingement syndrome

http://www.youtube.com/watch?v=wr_FBVjHJY8

Impingement syndrome

• Inflammation of the subacromial space

– The area under the acromion and above the glenohumeral joint

– Structures in this space• Supraspinatus

• Subacromial/subdeltoidbursa

Subacromial bursa Supraspinatus

Approach

1. Posterior

2. Lateral

Slide courtesy of Anthony Luke, M.D.

Subacromial Injection

Posterior approachLandmarks• Posterior and lateral

borders of acromion• CoracoidTechnique• Insert needle at Posterior

“soft spot”• Aim parallel to angle of

lateral acromion to reach subacromial bursa

• Direct needle towards opposite nipple


http://www.aafp.org/afp/2003/0315/p1271.html


Lateral approach

Landmarks• Lateral border of the acromion

Technique

• Inject 3 mm below lateral border of the acromion

• Angle needle parallel to plane of the acromion



• 5 – 8 mL combination of local anesthetic solutions

• 1 – 2 mL steroid solution

My preferred solution:

• 5 mL 1% lidocaine with 1 mL 40 mg/mL triamcinolone

Subacromial injection palpation

Subacromial injection

Thank you

Questions?

[email protected]

Documents

Mastering the MSK Exam and Procedures in · PDF fileOffice Procedures in Orthopaedics ... Knee Anatomy. The quadriceps ... who had joint aspirated at time of injection in knee OA