Shoulder and Knee Exam Workshop Wade M Rankin

Shoulder and Knee Exam Workshop Wade M Rankin, DO, CAQSM Kelly Evans-Rankin, MD, CAQSM UK College of Medicine Department of Family and Community Medicine

• Thank you KAFP for allowing us to present at today’s workshop!

Disclosure We have no financial or other disclosures that would influence this presentation

Educational Need/Practice Gap = The number of unnecessary referrals to Orthopedics for common joint aches and pains. Need = To increase the comfort level of diagnosing and treating common musculoskeletal issues within the primary care setting.

Objectives • Discuss special tests and utility in both knee and shoulder exam • Demonstrate both the shoulder and knee exam • Provide opportunity for hands-on small group participation of exam techniques

Expected Outcome - Increase the comfort level of primary care physicians in diagnosing and treating common musculoskeletal issues.

The Shoulder Exam:

Anatomy • 30 muscles • 3 bones – Scapula, humerus, clavicle • 4 joints/articulations – Sternoclavicular joint, acromioclavicular joint, glenohumeral joint, scapulothoracic joint

Musculature • Abductors – Deltoid (ant/medial), supraspinatus • Adductors – Pecs, deltoid(rear), lats • Flexors – Deltoid • Extensors • External rotators – Supraspinatus, infraspinatus, teres minor • Internal rotators – Subscapularis, pectoralis minor

Rotator Cuff • 4 Muscles – – – Supraspinatus Infraspinatus teres minor Subscapularis “SIt. S”

Rotator Cuff • Supraspinatus – origin from superior scapula (above spine) and inserts on greater tubercle of humerus – Active in a. BDuction and external rotation – Tested with empty can test, resisted external rotation, Neer (ear) and Hawkin’s test – #1 rotator cuff muscle to be injured/inflamed

Rotator Cuff • Infraspinatus – Origin on Scapula (under spine) and inserts on greater tubercle of humerus – Externally rotates the humerus – Hard to isolate in testing – Can be injured along with supraspinatus, not usually isolated injury

Rotator Cuff • Teres Minor – Origin on the lateral border of the scapula, inserts on the greater tubercle of the humerus – Externally rotates the humerus – Hard to isolate in testing – Usually not injured in isolation

Rotator Cuff • Subscapularis – Origin on the anterior surface of scapula and inserts on the lesser tubercle of the humerus – Depresses the humeral head and internally rotates – Tested with the lift off test and can be tested with pushing on patients stomach (harder to isolate), Bear Hug test – Usually torn with fall on outstretched arm or with forced extension

Inspection • Look for symmetry between affected and unaffected side • Any atrophy to infraspinatus or supraspinatus? • One side higher than other? • Any scapular winging?

ROM Testing • Active Motion Testing – Check for Scapulothoracic Motion testing • Stand behind patient as he/she forward flexes • Is the motion fluid/smooth, any protraction/retraction of the scapula? – Active ROM • Full forward flexion, extension, abduction • Fluid or jerky?

ROM Testing • Passive ROM testing – You move the patient’s arm into the different positions – Are there anatomical limitations to movement? – Any crepitus or pops/cracks? – Fluid movement?

Palpation • Area of greatest tenderness- ask patient to point with one finger • Palpate over bicipital groove • Acromioclavicular joint • Subacromial scpace • Scapulothoracic musculature (trapezius, rhomboids, levator scapulae)

Special Tests: Glenohumeral Instability – Sulcus test – Apprehension/Relocation test

Special Tests: Glenohumeral Instability • Sulcus test • Pt holds his/her arm down by the side • Examiner grabs arm above elbow and gives a gentle downward force • With instability-the humerus will translate inferiorly and will become visible • Dyssymmetry important • Sens-90%, Spec-85%

Special Tests: Glenohumeral Instability • Apprehension/Relocation Test – Apprehension Test • Pt lays supine on table and examiner a. BDucts humerus to 90 degrees and ER the arm • Any pain or apprehension or unwillingness to complete the test is positive • Sens-69%, Spec-50% – Relocation Test • If pt has positive apprehension test, if the pain resolves when the examiner places a downward force on the humerus, the test is positive • Sens-68%, Spec-100% if used in combo with apprehension test

Special Tests: Acromioclavicular (AC) Joint – Cross arm a. DDuction test

Special Tests: Acromioclavicular (AC) Joint • Cross Arm ADDuction test (Apley Scarf Test) • Pt flexes to 90 degrees • ADDucts humerus • Test is positive if pain over AC joint with this maneuver • No Sens/Spec data

Special Tests: Rotator Cuff • Supraspinatus (RTC) Strength Testing – Empty can test (supraspinatus) – ER testing (supraspinatus, infraspinatus, and teres minor)

Special Tests: Rotator Cuff • Supraspinatus Strength- “empty can” test – Pt flexes to 135 degrees and IR (thumbs down) – Pt resists downward force applied by examiner – Smooth giving way of strength is positive test – Sens-18. 7%, Spec-100% for detecting tears

Special Tests: Rotator Cuff – IR/ER testing • Pt humerus a. DDucted with elbow at 90 degrees • Pt resists examiner with testing of ER and IR • Tests the infraspinatus, teres minor, supraspinatus, subscapularis (IR)

Special Tests: Rotator Cuff • Subscapularis Testing – Lift Off Test – Belly Press – Bear Hug Test

• Lift Off Test Special Tests: Rotator Cuff – Test subscapularis • Pt IR and places hand by back pocket • Sens-50%, Spec-95. 4% for detecting tears • Belly Press – Test subscapularis • Pt press palm of ipsilateral hand into belly • Examiner assess strength of IR

Special Tests: Rotator Cuff • Bear Hug test – Tests the subscapularis • Pt places palm of ipsilateral hand on the contralateral shoulder • Pt then resists anterior translation of the palm • Weakness is a positive test

Special Tests: Biceps Tendon • Biceps Tendon Tests – Speed’s Test – Yergason’s Test

• Special Tests: Biceps Tendon Speed’s Test – Test for long head of biceps tendon – Pt flexes to 90 degrees with palm/thumb up – Pt resists downward force applied by examiner to palm of patient – Positive test is pain in the bicipital groove – Sens-68. 5%, Spec-55. 5%

Special Tests: Biceps Tendon • Yergason’s Test – Test for long head of biceps tendon – Elbow flexed to 90 degrees and pronated – Examiner then resists the pt’s active supination – Pain over the bicipital groove is a positive test – Sens-37%, Spec-86. 1%

Special Tests: Impingement/RTC Tendonitis • Tests for Impingement/RTC Tendinitis – Neer’s Test (ear) – Hawkin’s Test

Special Tests: Impingement/RTC Tendonitis • Neer’s Test (ear) • Pt’s humerus is flexed to 180 degrees and a. DDucted by the ear • Test is positive when pain is elicited • Sens-75%, Spec-47. 5%

Special Tests: Impingement/RTC Tendonitis • Hawkin’s Test • Pt’s humerus is elevated to 90 degrees and forcibly internally rotated • Test is positive if pain elicited • Sens-91. 7%, Spec-44. 3% • Neer + Hawkin’s yields Sens-70. 8%, Spec-50. 8%

Special Tests: Labrum • Tests for labrum – SLAP or O’Brien’s Test

Special Tests: Labrum • SLAP test aka Obrien’s test – Test for labral pathology • Pt flexed to 90 degrees, adducted 15 degrees and internally rotated (thumb down) • Pt resists the downward force on the palm applied by the examiner • Positive test is pain/click with maneuver relieved when patient turns palm up • Sens-100%, Spec-98. 5%

Questions about the shoulder exam?

The Knee Exam:

Knee Anatomy • Bones – Femur, tibia, patella, fibula • Ligaments – – Anterior cruciate ligament Posterior cruciate ligament Medial collateral ligament Lateral collateral ligament • Cartilage/Meniscus – Medial/Lateral meniscus

Knee Anatomy • Tendons – Quadriceps Tendon – Patellar Tendon – Iliotibial Band

Inspection • Expose both knees completely • Observe walking-limp or antalgic? • Any muscle wasting? • Any varus or valgus deformity? • Any scars present? • Any redness or swelling? • Any rashes?

Palpation • Have patient point with one finger the area of maximal tenderness • Important to compartmentalize where the pain is coming from (ant/post/lateral/medial) for differential diagnosis

Palpation • Palpate pertinent anatomy – Joint lines-meniscal injuries – Med/lateral patella- PFS – Lateral femoral condyle- IT Band syndrome or LCL injury – Medial femoral condyle- Pes anserine bursitis or MCL injury – Posterior knee- Baker’s cyst – Patellar tendon- patellar tendinitis – Tibial tuberosity- Osgood Schlatter

ROM Testing • • Flexion- normal 130 degrees Extension- normal zero degrees Internal Rotation External Rotation

Special Tests: Patella • Patellar pathology – Patellar apprehension test – Patellar grind test

• Special Tests: Patellar apprehension test – Examiner puts lateral and medial glide to patella – Pt will have pain or feel as if his/her patella will sublux or dislocate

• Special Tests: Patellar grind test – Patient puts AP compression to patella and medially/laterally translates patella – Crepitus or grinding with translation is a positive test – Can also be performed by having the examiner translate the patella inferiorly and the pt contracts the quadriceps which makes the patella move in the trochlear groove- if crepitus/grinding-positive test – Test for patellar pathology including subluxation or chondromalacia patellae

Special Tests • Ligamentous Pathology – Lachman’s test – Reverse Lachman’s test – Ant/Post Drawer test – Pivot shift test – PCL sag test – Varus/valgus test – Figure Four test

• Special Tests: ACL Lachman’s Test – Test for ACL/PCL integrity – Examiner grasps the femur with one hand the tibia with the other (knee should be in 30 degrees of flexion) and moves the joint in the AP direction – Positive test is an endpoint that is not firm or increased motion in either ant/post direction compared to unaffected side

Special Tests: ACL • Reverse Lachman’s test – Hard to do Lachman’s test if pt with big legs or examiner with small hands – Have pt lie prone with knee in 30 degrees of flexion (resting distal tibia on examiner thigh) – Examiner then translates the thigh anteriorly, if no firm endpoint positive test for ACL injury

• Special Tests ACL/PCL Anterior/Posterior Drawer test – Test integrity of ACL/PCL – Pt flexes knee to 90 degree with foot flat on the table – Examiner sits on pt’s foot after externally rotating tibia about 15 degrees – Examiner then translates anteriorly and posteriorly after asking the pt to relax hamstring complex – Positive test is a non firm endpoint or increased translation when compared to the opposite side

Special Tests ACL • Pivot Shift Test – Test for ACL integrity – Examiner grasps the leg with both hands, one hand on foot/ankle with slight internal rotation, the other providing valgus force with knee in about 20 degrees of flexion – The knee is then extended and the test is positive if a subluxation or clunk of the tibia is noted

• PCL sag test Special Tests: PCL – Test integrity of the PCL – Pt lays supine with hips and knees both in 90 degrees of flexion – Examiner looks perpendicular to proximal tibia – Positive test if tibia “sags” when compared to unaffected side – If pt extends knee against resistance, PCL deficient knee will have superior translation of proximal tibia and be in same position as other knee

• Special Tests: MCL/LCL Varus/Valgus test – Test the integrity of the MCL/LCL – Test should be performed at both zero degrees and 30 degrees – Examiner puts one hand on distal tibia and the other hand on the knee – Varus test, 1 hand on medial knee, the other on the distal tibia- varus pressure applied – Valgus- reverse hands – Positive test is laxity with no firm endpoint

Special Tests: LCL • Figure Four Test – Test for LCL Sprain – Pt supine with heel of affected leg on the knee of the contralateral leg – Examiner palpates the LCL – Pos test if painful with maneuver or TTP over the LCL

Special Tests: Meniscus • Meniscal Pathology – Thessaly Test – Mc. Murray’s Test – Apley’s Grind Test

Special Tests: Meniscus

• Special Tests: Meniscus Mc. Murray’s Test – Test for meniscal pathology – Pt supine with knee/hip flexed to 90 degrees – Examiner ER lower leg and flexes/extends the knee while palpating medial/lateral joint line – Pos test is a click palpated in the joint line

Special Tests: Meniscus • Apley’s Grind Test – Test for meniscal pathology – Pt prone with knee in 90 degrees of flexion – Examiner applies force down through the heel while IR/ER – Positive test is pain with the maneuver

Strength Testing • Quadriceps testing • Hamstrings testing • Hip a. BDuctors/a. DDuctors

Questions about the knee exam? • LET’S PRACTICE…

Thank you very much for your time!

• Following Slides are for Information to review and put everything together • Advise to review and work through the test to arrive at your diagnosis.

Outcomes • Medial knee pain – MMT – Pes Anserine Bursitis – MCL sprain – OA

Outcomes • Medial Knee Pain – MMT- +Mc. Murray’s, +Apley, TTP medial joint, Neg Valgus test – Pes anserine bursitis- -Mc. Murray’s, -AGT, TTP over bursa, +Valgus test – MCL sprain- +Valgus test, TTP over insertion/origin of MCL – OA- +/-Mc. Murray’s test, +/-AGT, ? medial joint line tenderness, +/- Valgus test

Outcomes • Lateral knee pain – LCL sprain – LMT – Iliotibial Band Friction Syndrome

Outcomes • Lateral knee pain – LCL- + Varus test, + Figure Four test, TTP over LCL – LMT- +Mc. Murray’s, +AGT, TTP over lateral joint line – ITB Syndrome- TTP over lateral femoral condyle, +Ober’s test, otherwise normal

Outcomes • Anterior knee pain – Patellofemoral syndrome – Patellar tendinitis – Patellar subluxation/dislocation – Osgood Schlatter

Outcomes • PFS- +patellar grind, TTP around patella, weak hip a. BDuctors, increased Q angle • Patellar tendinitis- TTP over patellar tendon, jumper • Patellar sublux/D/L- +patellar apprehension, +patellar grind, TTP over patella • Osgood-Schlatter- TTP over tibial tuberosity, history

Outcomes • Posterior Knee Pain – PCL injury – Baker’s cyst – Can have post pain with post horn meniscal tear (uncommon-but keep in mind)

Outcomes • PCL tear- +Sag test, +Lachman’s, +Post Drawer test • Baker’s cyst- palpable fullness, lump