41 Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossaAlmost always anterior (95%)Usually traumatic with injury to capsule-labrum complex
42 Shoulder Dislocation/Anterior Instability TreatmentReduction of dislocationProtection & rehab, rehab, rehabMost will have future dislocations and/or instabilityAt least 70%!!! (young)May require surgical tightening/repair of the capsule/labrum complex
43 Special Tests Glenoid Labrum and Instability Biceps Load I and IIKim TestJerk TestActive-Compression Test (O’Brien)Crank TestApprehension TestRelocation TestLoad and ShiftSulcas Sign
44 Which of the following structures can be “impinged”? Biceps tendonSubacromial BursaRotator Cuff TendonsAll of the above3010
45 Case #3 35-year-old male tennis player Shoulder pain exacerbated by practicing servesDevelops dull, aching pain in right shoulder
46 SHOULDER PAIN Physical Exam Tenderness to palpation anterior shoulderPain with abduction starting around 90 degreesUnable to lift arm past 120 degreesPain with forward flexion at degreesSpecial Tests??? Diagnosis???
48 Impingement as a Clinical Sign Repetitive overhead activitiesSubacromial bursa and/or rotator cuff impinged between acromion & humerusPhysical therapy, activity modification +/- medications
49 Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophyAC joint arthrosis and /or bone spursRotator cuff diseaseSuperior labral injuryGlenohumeral instabilityScapular dyskinesisBiceps tendinopathyA diagnostic injection sometimes helps to clarify the diagnosis
50 Case #4 45-year-old weight lifter Caught bar as it was falling off his shoulderSudden painSevere weakness left shoulderWorse with overhead activities; while sleeping at nightPain in anterior lateral shoulderSpecial tests?
51 Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can SignNormal bear hug and belly press tests…Diagnosis?????51
52 Rotator Cuff Tear Supraspinatus tendon most common Acute trauma or chronic tendinopathyTreatment dependent upon age/activityYoung, active usually require operative treatmentOlder, low-activity usually respond to non-operative treatment
53 Case #5 42-year-old female with dull pain right shoulder Pain is diffuse in natureSometimes spreads to between shoulder bladesSeems worse at night
54 Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam Not able to reproduce pain during examWhat else do you want to do???
55 Shoulder pain isn’t always the shoulder!! Get more history… Gall bladder diseasePeptic Ulcer DiseaseCervical radiculopathyCardiac ischemiaPulmonary conditionsie Pancoast’s tumor, Pneumonia
56 In the human body, which is the most incredible joint? PIPKneeAnkleShoulderNone of the above
57 Case #6 40-year-old male Recently shoveled 16” of snow Can hardly lift left arm due to painSpecial Tests? Diagnosis?
76 Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90°Instruct patient to slowly lower armAt 90° abducted arm will suddenly drop, may need to add slight pressure(+) drop = (+) test76
77 Speed’s Test Biceps Tendinopathy Long head of biceps tendonitisFwd flex to 90°, abd 10°, full supinationApply downward force to distal armPain = (+) testweakness w/o pain = muscle weakness or rupture77
78 O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathologyArm flexed to 90°, elbow extended, adduct 10-15°, resist downward force+ if AC pain or internal pain/click78
79 O’Brien’s Active Compression SLAP lesion Supination should be pain free (decreased pain)79
80 Crank Test Labral injury Glenoid labrum tearAbduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other(+) if audible/painful catch/grind is noted80
88 Anatomy – Menisci of the Knee Medial meniscusLateral meniscusMeniscal ligamentsFunctions of the menisciMeniscal zonesWhite-whiteRed-whiteRed-red
89 Knee Exam Overview Inspection Palpation Range of Motion Strength NeurovascularSpecial Tests
90 Case 1 – Medial Right Knee Pain 16yo HS soccer player, previously healthyTackled from right side while runningImmediate onset of medial jt line painDelayed onset local medial edema, stiffnessAble to bear weight
91 Key Questions in the History Mechanism of Injury?Acute or Chronic?Location and level of pain?Able to walk?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?
92 Case 1 - Exam Inspection: Mild medial knee edema Palpation: + ttp medial kneeROM: can’t bend >80dStrength: mildly decreasedNeurovascular: normalSpecial tests:Neg Lachman, Anterior Drawer, McMurray, varus stress+ mild increased gap on valgus stress (compared to left) with good endpoint
101 What grade of sprain is likely present of the MCL? Grade 1: no laxity, but hurtsGrade 2: mild laxity, still intactGrade 3: complete tearGrade 4: hurts like *^%*
102 MCL Sprain Treatment? RICE Relative Rest Hinge Brace only if unstable on examAchieve full ROMProgressive StrengtheningNeuromuscular Control (Balance exercises)Functional Exercises (Sport-specific)
103 Case 2 56 yo retired Army LTC 15 years worsening L>R knee pain Former parachutist, no specific traumaNo previous knee surgeriesStiffness worse in morningPain is worse with activity, better with rest
104 Case 2 – Key Questions Insidious Onset Mechanism of Injury? Chronic Difficult to localize; mildNoNoneOccasionalLots of “Bad Landings” No surgeryActivityRestMechanism of Injury?Acute or Chronic?Where/how bad is pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?
105 Case 2 – Physical Exam Inspection: Genu varusBony enlargement at Med/Lat joint linesPalp: Posterior medial joint line ttpROM: Decreased flexion, 110 deg, mild crepitusStrength: normalNeurovascular: normalSpecial Tests: no ligamentous laxity, neg meniscal tests
106 Special Tests - Meniscal Injuries Joint line tendernessMcMurray TestsThessaly testBounce-home testFull Squat106
107 Case 2 – Plain Films Joint space narrowing Subchondral Sclerosis OsteophytesSubchondral Cysts
108 What is your diagnosis? Meniscal tear Plica syndrome Osteoarthritis Bone tumor10
110 Case 3 31 year old female, L knee pain Recreational runner Localizes pain to front of kneeNo trauma, insidious onsetLocalizes pain “around kneecap”Worse with stairsWorse after prolonged sittingKnee occasionally “gives out”
111 Case 3 – Key Questions Insidious Onset Mechanism of Injury? Chronic Anterior kneeNo, but sometimes gives outNoneRunning, StairsMultiple days of restMechanism of Injury?Acute or Chronic?Where is the pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?
119 Case 4 34 yo Army MAJ training for 1st marathon Atraumatic onset of R lateral knee pain 1 week ago after 10 mile runSharp burning painBetter with rest, returns with running
120 Case 4 – Key Questions Insidious Onset Mechanism of Injury? Acute Lateral kneeNo, but sometimes gives outNoneRunningMultiple days of restMechanism of Injury?Acute or Chronic?Where is the pain?Mechanical Symptoms? (Locking, popping, catching?)Associated instability?Swelling?Previous injuries or surgeries?What makes it worse?What makes it better?
121 Physical Exam Inspection: normal Palpation: TTP over lateral femoral condyleROM: fullStrength: normalNeurovascular: normalSpecial tests:+ Noble testTight on Ober test
127 Before we break for hands-on Questions?Before we break for hands-on
128 Special Tests - ACL Injury Lachman TestKnee flexed to degreesStabilize distal femurAnteriorly translate tibia on femurWatch & feel for amount of translation & end pointPivot Shift128
129 Special Tests - PCL Injury Posterior Drawer TestKnee flexed to 90 degreesPosteriorly translate tibia on femurWatch & feel for amount of translation & end pointSag SignKnees flexed, quads relaxed compare both sidesLook for tibial posterior “sag” relative to femurQuad-Active TestKnee flexed; hamstrings fully relaxedSlide foot along table (quad active)Observe for anterior relocation129
130 Special Tests - MCL Injury Valgus Stress TestingKnee flexed to 30 degreesRelax ACL/PCL & joint capsuleValgus stress applied to kneeLook and feel for translation and endpointCompare to uninjured sideMay repeat with knee in full extension130
131 Special Tests - LCL Injury Varus Stress TestingSame test as valgus stress testingExcept applying a varus stress insteadLCL, IT band, & PLC are tested131
132 Special Tests - Meniscal Injuries Joint line tendernessFull SquatMcMurray TestsThessaly testBounce-home test132
133 McMurray test for Meniscal injury Test Med and Lat meniscus separately3 concurrent maneuvers:Grind it (Rotate tibia AWAY from it)Crunch it (varus or valgus)Pinch it (flex/extend knee)Positive: Painful “pop”Patient supineHeel of patient’s injured leg held while knee fully flexedFingers of other hand palpate medical joint line while thumb palpates lateral aspect of jointValgus stress appliedPatient’s knee extended with tibia held externally rotatedPain or palpable click over medial joint line indicates medical meniscal tear133
134 Special Tests - Meniscal Injuries Thessaly TestPt stands on affected legKnee bent at 20 degreesExaminer holds pt’s hands and rotates pt to both sidesMeniscal grindPositive test: pain, painful click.
135 Anterior Knee Exam Palpation of patellar facets Glide and lift patella medially & laterallyPalpate undersurface of patella for tenderness
137 Anterior Knee Exam Patellar Grind Test Knee 10 deg flexion Glide patella distally, and firmly compress patella against trochlear grooveActive quadriceps contraction pain
138 Special Tests – Ober’s Test Lateral decubitus with testing side up, testing knee flexedAdduct and fully flex hip Abduct, externally rotate, & extend hipSlowly release support against gravity from leg, allowing gravity to take leg towards tablePositive test: leg remains abducted despite examiner releasing leg
139 Special Tests Noble’s test Palpate lateral femoral condyle Flex and Extend Knee+ Test is pain at site of palpation