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Tom Winters, MD, FACOEM, FACPM Chief Medical Officer

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Presentation on theme: "Tom Winters, MD, FACOEM, FACPM Chief Medical Officer"— Presentation transcript:

1 Provocative Testing & Diagnostics of Upper & Lower Extremity Conditions
Tom Winters, MD, FACOEM, FACPM Chief Medical Officer CareGroup Occupational Health Network Walter Panis, MD Medical Director June 6, 2002 Copyright 2002 CareGroup Occupational Health Network

2 The Knee Approx million knee injuries per year in general population Why so many injuries Largest joint in body Dynamic nature of joint increases vulnerability Very little bony stability- relies on normal ligaments, cartilage and tendons Ref: AAOS Research Dept., Pt. Visits for selected conditions, 1998

3 Anatomy of the Knee Bones: Cartilage (shock absorbers) Femur Tibia
Patella Cartilage (shock absorbers) Lateral Meniscus Medial Meniscus Articular cartilage is nerveless

4 Anatomy of the Knee Ligaments 4 major ligaments (attach bone to bone)
Anterior Cruciate Posterior Cruciate Medial Collateral Lateral Collateral

5 Anatomy of the Knee Patellar and Extensor tendons (attach Quadriceps to bone) Major tendons Synovium Inner joint lining Synovial fluid Joint lubrication

6 Types of Knee Injuries ACL tear Bursitis (“Housemaids knee”)
Collateral ligament tear Posterior ligament tear Meniscal tear Fracture of tibia Fracture of patella Sprain/strain Patellar/quadriceps tendinitis Patellofemoral pain Extensor mechanism rupture

7 Types of Knee Injuries Ligament Injuries
ACL: changing direction quickly, twisting, pivoting, deceleration activities PCL: blow to front of knee (“dashboard injury”), hyperextension / hyperflexion MCL: contact with outside of knee, valgus force (common) LCL: knee forced laterally, varus force (less common)

8 Types of Knee Injuries (cont.)
Meniscal Tears Medial/Lateral Meniscal Tear: Twisting,cutting, pivoting, rapid deceleration types of motions Movement around a fixed lower leg (stationary) or planted foot

9 Examination of the Knee
Inspection (always examine uninjured knee 1st!) Note onset- acute/gradual Type/quality of pain Posture Bony deformities Muscle wasting Quad wasting esp. in VM O seen with knee injury Soft tissue swelling Effusion of suprapatellar pouch, pre and infrapatellar bursae, palpable joint line swelling Masses/lumps Old scars Pulses

10 Examination of the Knee (cont.)
Palpation Check bilaterally for temperature differences, inflammation Palpate medial and lateral collateral compartments Bursae Medial/lateral meniscus Medial/lateral ligament Medial more common “Bucket-handle” tear Popliteal fossa

11 Examination of the Knee (cont.)
Palpation (cont.) Bony landmarks Medial and lateral joint lines Patello-femoral joint Tibial tuberosity Femoral condyles Reflexes Always check joint above and below (hip and ankle); hip pain may be referred to knee!

12 Examination of the Knee (cont.)
Range of motion Flexion = 130+ degrees Extension = 0 - (-10) degrees

13 Special Knee Tests Tests for ACL laxity Anterior drawer sign
Lachman’s test Pivot shift Anterior Draw Test Lachman’s Test Ref: Snider, R. The Essentials of Musculoskeletal Care. AAOS: 1997

14 Special Knee Tests (cont.)
Posterior sag sign PCL stress tests Posterior sag sign Reverse Lachman’s Posterior draw sign Reverse pivot test

15 Special Knee Tests (cont.)
McMurray’s/ Apley’s grind test (meniscus) Apprehension test (patella) Crepitus sub-patella Pathological “locking/giving out” Due to intra-articular fragment of bone or cartilage wedging between femoral & tibial condyles Joint unable to fully extend (fixed flexion deformity) McMurray’s Test Ref: Hoppenfeld,S. Physical Examination of the Spine & Extremities. Prentice-Hall: 1976.

16 Grading Ligament Injuries
Grade I (sprain): Micro-tearing or stretching Joint is stable Grade II (sprain): Partial disruption of ligament Painful to stress joint Joint laxity with endpoint Mild effusion Grade III (tear): Complete tear Joint laxity without endpoint   effusion

17 Diagnostic Procedures
X-ray Indications MRI Best to view: Meniscus, ligaments, soft tissue CAT Scan Bone

18 Diagnostic Procedures
Arthrogram (infrequently performed) Arthroscopy (preferred method)

19 Treatment of Knee Injuries
Rest Ice Compression Elevation Anti-inflammatories NSAIDs COX-2

20 Types of Knee Braces Types of bracing:
Prophylactic Functional Rehabilitative/knee immobilizer Patellorfemoral Often work better in lab than in real life use Functional and Rehabilitative seem to be of most use Stretching, strengthening,and technique improvement more important in long run

21 Anatomy of the Foot and Ankle
                                                               Bones “True ankle joint” Tibia Fibula Talus Second part of ankle Subtalar joint Calcaneus (heal) Foot Tarsals Metatarsals Phalanges Ref:

22 Anatomy of the Foot and Ankle (cont.)
Cartilage & ligaments Articular cartilage (1) Anterior tibiofibular (2) Connects tibia to fibula Most commonly injured Collateral lateral ligaments (3) Attaches fibula to calcaneus- lateral stability Deltoid ligaments (4) Connect tibia to talus and calcaneus- medial stability                                                   Ref:

23 Anatomy of the Foot and Ankle (cont.)
Tendons Achilles tendon Anterior tibial tendon Posterior tibial tendon

24 Examination of the Ankle and Foot
Inspection Ecchymosis, bony abnormalities, soft tissue swelling, effusion Note type of footwear- note wear pattern on soles Gait Palpation Tenderness- certain areas of foot normally tender i.e.sinus tarsi, distal aspect of ball between metatarsals Neurovascular status- Pulses, sensation Crepitation Tinel’s sign (+ peroneal nerve injury) Range of motion

25 Special Tests of the Ankle and Foot
Eversion stress (Medial stress test) Drawer test Anterior drawer test (tests stability-ATF ligament) Lateral stress External rotation test (Kleiger test) Squeeze test (testing for fx of tibia or fibula) Heel tap test

26 Types of Ankle and Foot Injuries
Plantar fasciitis Tarsal tunnel syndrome (ladders) Insertional Achilles tendinitis Stress fracture of calcaneus March fracture (stress fx) Sesamoiditis Fracture of the sesamoid

27 Sprain versus Strain Sprain: twisting of joint that stretches or tears ligaments, no dislocation of bones, may damage nearby blood vessels, muscles, tendons, swelling and hemorrhage Strain: less serious injury, overstretched tendon or partially torn muscle

28 Types of Ankle Injuries: Sprains
1st degree: no (mild) edema, point tenderness, ligament stretching, no rupture (maybe crutches/cane) 2nd degree: partial ligament rupture, edema, point tenderness, difficulty/inability to weight bear on ankle (crutches,splint) 3rd degree: complete disruption one or more ligaments/other structures,   edema, ecchymosis, general tenderness, inability to bear weight (crutches,splint, cast, surgery)

29 Ankle Sprains Forced inversion strain Forced eversion strain
Stretch, tear or rupture of lateral collateral ligament complex (possibly anterior talo-fibular lig.) Forced eversion strain Stretch, tear or rupture of medial collateral ligament Lateral ankle compartment more commonly injured than medial

30 Foot and Ankle Fractures
Types Jones (fx of proximal metaphysis of 5th metatarsal) Diagnosis Routine use of x-rays to rule out sprain vs. fx “to do or not to do”- clinical indications Ottawa rules for foot and ankle radiographs (see web site) org/afp/980201ap/wexler.html Treatment ORIF Casting

31 Foot and Ankle Fractures

32 Traumatic Injury Direct trauma = external force strikes the foot
Indirect trauma = force transmitted to stationary foot so that weight of body becomes a deforming force by torque, rotation or, compression Ref:

33 Pain Why are ankle injuries so painful?
Rich nerve supply (pain and proprioception is enhanced) All ligaments have poor blood supply: slow to heal, heals with scar tissue, retains stretched condition

34 Non-Surgical Treatment of Ankle Injuries
Rest Ice Compression Elevation

35 Types of Ankle Support Non-rigid (1st degree sprains):
Elastic wrap/neoprene Not OSHA recordable Purpose: compression, non-supportive Rigid: (1st, 2nd, 3rd degree sprains) Lace-up, Aircast Purpose: support, proprioception Bracing AFO (ankle foot orthosis) Walking boot Cast shoe Cast

36 Physical Therapy for Knee and Ankle Injuries
Does every lower extremity injury require physical therapy? Benefits How soon after injury should it be ordered? Home exercises versus clinic therapy program Nature of injury Patient compliance issues

37 Goals of Rehabilitation
Restoration of comfort Decrease edema R.I.C.E. Address pain NSAIDs COX-2 agents Refer complications early Maintain Mobility Active ROM & strengthening Restore proprioception Wobble board, mini-trampoline Work-hardening program or job specific exercise programs Prevent future re-injury Education Understand injury, treatment, rehab and prevention strategies

38 Upper Extremity Evaluation
History Exam Diagnostic studies Key is putting all three together to make a “total” picture

39 Low Back Pain Most commonly seen musculoskeletal injury
In normal population 80% of us will have an LBP episode in their lifetime 3-4% per yr. Will be temporarily disabled 1% of working population will be permanently disabled Ref:

40 Myths of Low Back Pain True or false:
All people with LPB need an x-ray Rest is good for pain MRI or CT must be done to provide definitive diagnosis Vast majority of patients improve in 2-6 weeks with or without treatment (approx. 90%)

41 Anatomy of the Lumbar Spine
No lateral support in lumbar spine (> mobility in sagittal and coronal planes) Bony vertebrae Transverse and spinous processes Intervertebral disc Outer annulus fibrosis Inner nucleus pulposus

42 Anatomy of the Lumbar Spine
Anatomical relationship between L4, L5 and S1

43 Anatomy of the Lumbar Spine
Specific nerve roots have specific functions and will elicit specific symptoms

44 Diagnosing Low Back Pain: Sprain/Strain Injury
Vast majority of LBP is a sprain/strain injury Ligamentous Tendonitis LBP most often over R lumbar sacral area Tends to be localized Referred pain not typically seen Described as “aching”

45 Diagnosing Low Back Pain: Nerve Root Compression
Back pain due to nerve root compression/radiculopathy less common “Sciatica” is not a good term Sciatic nerve= combination of tibial and peroneal nerve- forms well outside spinal canal where most back problems occur

46 Diagnosing Low Back Pain: Nerve Root Compression
Impingement compression pathology of spinal nerve root Initial complaint may be “electric shock down leg” Mechanism=  ICP due to   intrathoracic pressure   venous outflow from brain   ICP   pressure on nerve from disc causing burning/shooting pain Parethesias Numbness/tingling Bowel/bladder involvement Cauda Equina Syndrome Medical/surgical emergency

47 Diagnostic Studies for Low Back Pain
X-rays ? value MRI and CT scans Asymptomatic disc herniations are commonly found on What is diagnostic value of this? When should MRI or CT be done?

48 Two Common Presentations of Low Back Pain
History: 38 year old male experienced the following after lifting a 100 pound box from the floor to a shelf at work 1) Localized back pain OR 2) Very specific burning pain radiating to leg

49 Complaint #1 Physical exam findings Non-specific Reflexes normal
ROM, gait, posture Palpation of spine Response to light touch Provocative testing done Straight leg raise Heel to toe walk, squat and rise Palpation of sciatic notch

50 Complaint #1 Diagnostic testing Likely diagnosis
Not usually indicated unless red flags are present i.e. fever, wght. loss, hx of cancer, use of steroids etc. Likely diagnosis Low back strain/sprain

51 Complaint #1 Treatment NSAIDs Physical therapy
May need modified duty/work restrictions Importance of developing trusting relationship with patient to optimize outcome Lou Millender, MD “Love ‘em back to health!”

52 Complaint #2 Physical exam Specific
Motor weakness in specific distribution Abnormal reflexes Sensory loss Provocative testing ? Cauda Equina syndrome if unable to heel toe walk or squat + straight leg raise

53 Complaint #2 Diagnostic testing Likely diagnosis X-rays not useful
MRI after 6 weeks of conservative treatment unless neuro symptoms Electrophysiology studies What are they When are they done What will they show Likely diagnosis Radiculopathy

54 Complaint #2 Treatment Most improve on own Pain control
Physical therapy Prednisone/epidural steroids May need to be out of work for 1-2 days during acute symptoms Surgical intervention May require work restrictions/modified duty

55 Provocative Testing of the Shoulder
Apley scratch test Maneuver = touch superior/inferior aspects of opposite scapula Positive result (< ROM) = rotator cuff problem Neer’s test Maneuver = place arm in forced flexion with arm fully pronated Positive result (pain) = sub-acromial impingement Neer’s

56 Provocative Testing of the Shoulder
Crossed arm test Maneuver = raise arm to 90 degrees then actively adduct arm- forces the acromion into the distal end of the clavicle Positive result (pain) = disorder of acromioclavicular joint CROSSED ARM

57 Provocative Testing of the Shoulder
Hawkin’s test Maneuver = elevate arm forward to 90 degrees while forcibly internally rotating shoulder Positive result (pain) = subacromial impingement or rotator cuff tendonitis Drop arm test Maneuver = Passively abduct shoulder, observe pt. lowering arm to waist Positive result (arm will drop to side) = rotator cuff tear HAWKIN’S

58 Provocative Testing of the Elbow and Hand
Phalen’s test Maneuver = press back of hands together with wrists fully flexed, hold 60 seconds Positive result (numbness/tingling) = carpal tunnel syndrome, median nerve

59 Provocative Testing of the Elbow and Hand
Tinel’s sign Maneuver = tap over the carpal tunnel area (hand) or tap ulnar notch between olecranon process and medical epicondyle (elbow) Positive result (pain, tingling or electric sensation in hand) = carpal tunnel syndrome, median nerve in hand or ulnar nerve compromise in elbow

60 Case Studies MRI case study Electromyelogram case study Terminology
T1 and T2 weighting What to look for in the report Electromyelogram case study How they are done


62 References

63 References Karen Muller, MPT, Journal of Orthopaedic & Sports Physical Therapy, 2000;30(3): The Physician and Sports Medicine: Patellofemoral pain Taylor, S., P.T., “Diagnosis, Management and Treatment of Knee Disorders: The Extensor Mechanism”, PowerPoint Presentation, New England Baptist Hospital, 2001.

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