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Musculoskeletal Examination: General Principles and Detailed Evaluation Of the Knee & Shoulder Charlie Goldberg, M.D. Professor of Medicine, UCSD SOM Charles.Goldberg@va.gov General Principles \u2022 Musculoskeletal exam performed if symptoms (i.e. injury, pain, decreased function) \u2013 Different from \u201cscreening exam\u201d \u2022 Focused on symptomatic area \u2022 Musculoskeletal complaints commonÆfrequently examined Historical Clues \u2022 What\u2019s functional limitation? \u2022 Symptoms in single v multiple joints? \u2022 Acute v slowly progressive? \u2022 If injuryÆ mechanism? \u2022 Prior problems w/area? \u2022 Systemic symptoms? Examination Keys To Evaluating Any Joint \u2022 Area well exposed - no shirts, pants, etcÆ gowns \u2022 Inspect joint(s) in question. Signs inflammation, injury (swelling, redness, warmth)? Deformity? Compare w/opposite side \u2022 Understand normal functional anatomy \u2022 Observe normal activity \u2013 what can\u2019t they do? Specific limitations? Discrete event (e.g. trauma)? Mechanism of injury? \u2022 Palpate jointÆwarmth? Point tenderness? Over what structure(s)? \u2022 Range of motion, active (patient moves it) and passive (you move it). \u2022 Strength, neuro-vascular assessment. \u2022 Specific provocative maneuvers \u2022 If acute injury & painÆ difficult to assess as patient \u201cprotects\u201dÆ limiting movement, examination \u2013 examine unaffected side first (gain confidence, develop sense of their normal) Wrist Extension Flexion Elbow Flexion Extension Shoulder Abduction Adduction Hip Flexion Hip Extension Hip Abducition Hip Adduction Knee Extension Knee Flexion Plantarflexion Dorsiflexion Terminology: Flexion/Extension, Abduction/Adduction \u2022 Anatomic Position & Planes Of The Body \u2022 Flexion:Moving forward out of the frontal plane of the body (except knee and foot) \u2022 Extension:Movement in direction opposite to flexion \u2022 Abduction: movement that brings a structure away from the body (along frontal plane) \u2022 Adduction: movement that brings a structure towards the body (along frontal plane) Knee Anatomy: Observation & Identification of Landmarks \u2022 Hinge-type joint - tolerates sig force, weight \u2022 Anatomy straight forwardÆ Exam make sense! \u2022 Fully exposeÆtake off pants, use gown or shorts! \u2022 Surface land marks: patella (knee cap), patellar tendon, medial joint line, lateral joint line, quadriceps muscle, hamstring muscle group, tibia, anterior tibial tuberosity (insertion of patellar tendon), femur. Hamstring Muscles eOrthopod.com Knee Anatomy Observation (cont) \u2022 Obvious pain w/walking? \u2022 Landmarks \u2022 ScarsÆ past surgery? \u2022 SwellingÆfluid in the joint (aka effusion)? \u2022 Atrophic muscles (e.g. from chronic disuse)? \u2022 Bowing of legs (inward =s Valgus, outward =s Varus)? Varus Deformity (bowing outward) Surgical Scars Obvious right knee effusion Range of Motion (ROM) 1. Active then passive (you move the joint) 2. Hand on patella w/extens. & flex Æosteoarthritis, may feel grinding sensation (crepitus) Normal range of motion: Full Flexion: 140 Full Extension: 0 Assessment For A Large Effusion - Ballotment An effusion =s fluid w/in joint space \u2013 Large effusionsÆobvious To Examine: 1. Flex knee 2. Hand on supra-pateallar pouchÆabove patella, communicates w/joint space. 3. Push down & towards patellaÆ fluid center of joint. 4. Push down on patella w/thumb. 5. If large effusionÆpatella floats & "bounces" back up when pushed down. Menisci \u2013 Normal Function and Anatomy Femur (articular cartilage covers bone) Fibula Tibia Medial Meniscus Lateral Meniscus \u2022 Medial & lateral menisci on top of tibiaÆ cushioned articulating surface betwn femur & tibia \u2022 Provides joint stability, distributes force, & protects underlying articular cartilage (covers bone, allows smooth movement) \u2022 Menisci damaged by trauma or degenerative changes w/age. \u2022 Symptoms if torn piece interrupts normal smooth movement of jointÆ pain, instability ("giving out"), locking &/or swelling eOrthopod.com Anatomy&Function Meniscus Evaluating for Meniscal Injury \u2013 Joint Line Palpation Joint Line TendernessÆ medial or lateral meniscal injury (& OA) 1. Slightly flex knee. 2. Find joint space along lateral & medial margins. Joint line perpendicular to long axix tibia. 3. Palpate along medial, then lateral margins. 4. Pain suggest underlying meniscus damage or OA eOrthopod.com Meniscal Injuries Additional Tests For Meniscal Injury McMurray\u2019s Test \u2013 Medial Meniscus McMurray\u2019s manipulates kneeÆ torn meniscus \u201cpinched\u201dÆ Symptoms Medial meniscus: 1. Left hand w/middle, index, & ring fingers on medial joint line. 2. Grasp heel w/right hand, fully flex knee. 3. Turn ankleÆ foot pointed outward (everted). Direct kneeÆpointed outward. 4. Holding foot in everted position, extend & flex knee. 5. If medial meniscal injury, feel "click" w/hand on knee w/extension. May also elicit pain. Simulated McMurray\u2019s \u2013 Note pressure placed on medial meniscus McMurray\u2019s Test \u2013 Lateral Meniscus 1. Return knee to fully flexed position, turn foot inwards (inverted). 2. Direct knee so pointed inward. 3. Hand on knee, fingers along joint lines 4. Extend and flex knee. 5. If lateral meniscal injuryÆ feel "click" w/fingers on joint line; May also elicit pain. Note: McMurray\u2019s Test for medial and lateral meniscus injuries are performed together Additional Assessment For Meniscal Injury \u2013 Appley Grind Test 1. Patient lies on stomach. 2. Grasp ankle & foot w/both hand, flex knee to ninety degrees. 3. Hold leg down w/your leg on back of thigh 4. Push down while rotating ankle. 5. Puts direct pressure on menisciÆif injuredÆ pain. 6. Test opposite leg Simulated Appley \u2013 Note how downward pressure pinches menisci Ligaments \u2013 Normal Anatomy and Function \u2022 4 bands tissue, connecting femurÆtibia \u2013 provide stability \u2022 Ligamentous injury (requires significant force \u2013 eg leg struck from side w/foot planted)Æacute pain, swelling & often report hearing a "pop" (sound of ligament tearing). \u2022 After acute swelling & pain, patient may report pain & instability (sensation of knee giving out) w/maneuver exposing deficiency assoc w/damaged ligament Femur (articular cartilage covers bone) eOrthopod.com Knee Anatomy Fibula Tibia Medial Meniscus Lateral Meniscus Specifics of Testing \u2013 Medial Collateral Ligament (MCL) 1. Flex knee ~ 30 degrees. 2. Left hand on lateral aspect knee. 3. Right hand on ankle or calf. 4. Push inward w/left hand while supplying opposite force w/ right. 5. If MCL torn, joint "opens up" along medial aspect. 6. May also elicit pain w/direct palpation over ligament Compare w/non-affected side \u2013 \u201cnormal\u201d laxity varies from patient to patient Direction of Force eOrthopod.com Anatomy \u2013 Collateral Ligament Injuries Lateral Collateral Ligament (LCL) 1. Flex knee ~ 30 degrees. 2. Right hand medial aspect knee. 3. Left hand on ankle or calf. 4. Push steadily w/right hand while supplying opposite force w/ left. 5. If LCL torn, joint will "open up" on lateral aspect. 6. May elicit pain on direct palpation of injured ligament Direction of Forces eOrthopod.com Anatomy \u2013 Collateral Ligament Injuries Another Method For Assessing The LCL and MCL 1. Flex knee ~ 30 degrees, cradle heel between arm & body. 2. Place index fingers across joint lines. 3. Using your body & index fingers, provide medial then lateral stress to joint Anterior Cruciate Ligament (ACL) \u2013 Lachman\u2019s Test 1. Grasp femur w/left