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Beyond fractured bones: orthopaedic assessment of soft
tissue injuries
Ohood Elzibak, BHSc. PA, MPAS, CCPA
Canadian Certified Physician Assistant
Orthopaedic Surgery
Anne Dang, BHSc (Hons), BHSc PA, CCPA
Canadian Certified Physician Assistant
Orthopaedic Surgery
Outline
• Shoulder
• Knee
• Hip
• Elbow
Case IntroAnatomy ReviewCommon InjuriesPhysical ExamRevisit Case
ORTHOPAEDIC ASSESSMENT OF SOFT TISSUES
Shoulder Case
• Sam, 49 y/o steel factory worker• Presents with R shoulder pain x 2.5 years• No specific trauma• Intermittent, sharp pain, now interfering with
work
What else do you want to know?
SHOULDER
Common Shoulder Conditions
• AC Joint pathology• Osteoarthritis• Labral Tears• Shoulder Instability (MDI vs traumatic)• Impingement Syndrome• Rotator Cuff Pathology (tendonitis, tears)
SHOULDER - DIFFERENTIAL DIGANOSIS
Inspection
InspectionNeurovascular ExamPalpationROMStrengthSpecial Tests
http://shoulderspecialist.org/shoulder_bic.html http://www.bristolshoulderandelbowsurgery.co.uk/shoulder-problems/acj-injury-dislocation/
http://www.lipoma.net/lipoma-pictures http://www.dermis.net/dermisroot/en/18083/image.htm http://www.orthogurus.com/shoulder-replacement-faqs/http://www.kneeandshoulderclinic.com/shoulder/shoulder-dislocation/
SHOULDER - PHYSICAL EXAMINATION
Palpation
• Surface Anatomy• Palpate along bony
prominences and soft tissue landmarks
• Make note of points of tenderness
SHOULDER - PHYSICAL EXAMINATION
Range of Motion
• Forward Flexion• Abduction/Adduction• Extension
• Internal Rotation• External Rotation• ABER/ ABIR
SHOULDER - PHYSICAL EXAMINATION
Strength
Measured out of 5• Supraspinatus• Infraspinatus• Subscapularis• Deltoid
Grading Muscle Strength /5
Grade 5 – Normal
Grade 4 – Moves limb against resistance and gravity
Grade 3 – Moves limb against gravity
Grade 2 – Moves limb when gravity is eliminated
Grade 1 – Trace of movement with no joint involvement
Grade 0 – No Movement.
SHOULDER - PHYSICAL EXAMINATION
Special Tests
Hawkin’s Kennedy Test for Impingement
O’Brien’s Test for Labral Pathology
SHOULDER - PHYSICAL EXAMINATION
https://www.youtube.com/watch?v=hzgQcLuaFLw
http://www.internationalshoulderjournal.org/article.asp?issn=0973-6042%3Byear=2015%3Bvolume=9%3Bissue=1%3Bspage=6%3Bepage=8%3Baulast=Owen
Special Tests for Instability
AnteriorApprehension Test
Relocation Test
SHOULDER - PHYSICAL EXAMINATION
http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html
Special Tests for Instability
Sulcus Sign for Inferior Subluxation
Posterior Apprehension Test
SHOULDER - PHYSICAL EXAMINATION
http://seattleclouds.com/myapplications/Albertosh/Shoulder/EXPLORATION.024.jpghttp://www.specialistphysio.com/library/Sulcus%20sign%20stage2.jpg
Special Tests
Cross Arm Adduction Test for AC joint pathology
Speed’s Test for Long Head Biceps involvement
SHOULDER - PHYSICAL EXAMINATION
http://www.aafp.org/afp/2000/0515/p3079.html https://5minuteconsult.com/collectioncontent/30-160004/procedures/shoulder-exam-speeds-test-of-biceps-tendon
Revisiting shoulder case
49 year old male with R shoulder pain• On Physical exam:
– focal tenderness over greater tuberosity– ROM of affected side: Slightly decreased active
ROM in forward flexion & abduction, full PROM. – Positive Hawkin’s Kennedy Test, Positive Speed’s
Test. Negative O’Brien’s Test. Negative Apprehension Test.
– Power: SS: 4-/5, IS: 4/5, SubS: 5/5
SHOULDER CASE
Knee Case
- Teresa is a 29 y/o physiotherapist- Sustained a left knee injury while playing
soccer 5 weeks ago- Feels that she can’t trust her knee
What else do you want to know?
Common knee conditions
• Ligamentous Injury (ACL, PCL, LCL, MCL)• Meniscus Tears (Baker’s cysts)• Osteoarthritis• Patellofemoral Syndrome• Patellar Tendonitis• Prepatellar Bursitis• Pes Anserine Bursitis
Inspection
InspectionNeurovascular ExamPalpationROMStrengthSpecial Tests
KNEE - PHYSICAL EXAMINATION
http://www.medicalnewstoday.com/articles/187908.php http://www.ijcasereportsandimages.com/archive/2015/010-2015-ijcri/
CL-10086-10-2015-flannery/ijcri-1008610201586-flannery-full-text.php
https://bonesmart.org/knee/knee-replacement-complications/ http://shoulderskneesandconcussions.weebly.com/knee-injuries.html
http://emedicine.medscape.com/article/1170572-clinical?pa=jaREkfjIh8PFxj2dsfLPsa7J7sO4Ux%2B822vNE0Zzg%2BOUu4%2BU2L6ZgsOhTUF0NR%2FKvkg11Em4197HjcN9kOaZcbOwhd8Mdk7tVO%2FdkscsGC4%3D*ALSO INSPECT GAIT AND ALIGNMENT
Palpation
• Surface Anatomy• Palpate along bony
prominences and soft tissue landmarks
• Make note of points of tenderness
KNEE - PHYSICAL EXAMINATION
http://www.cram.com/flashcards/hip-knee-exam-2531474
Range of Motion
• Flexion• Extension• Hyperextension• Slight IR/ER (not
typically reported)
KNEE - PHYSICAL EXAMINATION
https://bonesmart.org/forum/threads/rom-range-of-motion-information.3730/
Strength
Measured out of 5• Quadriceps• Hamstrings
Grading Muscle Strength /5
Grade 5 – Normal
Grade 4 – Moves limb against resistance and gravity
Grade 3 – Moves limb against gravity
Grade 2 – Moves limb when gravity is eliminated
Grade 1 – Trace of movement with no joint involvement
Grade 0 – No Movement.
KNEE - PHYSICAL EXAMINATION
http://www.wikidoc.org/index.php/Knee_examination
https://corewalking.com/muscle-testing-check-your-hamstrings/
Special Tests
KNEE - PHYSICAL EXAMINATION
http://morphopedics.wikidot.com/medial-collateral-ligament-strain-of-the-knee
Revisiting knee case
- 29 y/o physiotherapist with left knee soccer injury
- On physical exam:- Normal inspection, slight valgus alignment- No tenderness on palpation- Full ROM (0-145)- Gr 5 quads and hamstrings strength- Gr 0 varus/valgus stress test, Gr 2-3 Lachman, Gr
2 pivot shift, Gr 0 posterior drawer test, negative McMurray’s
Hip Case
- Sami is a 30 y/o olympic rower- Presents with bilateral hip pain x 1 year, R>L- Worse after training for long periods- No improvement with physiotherapy and
athletic therapy
What else do you want to know?
Hip Anatomy
http://ernestschilders.com/hip-anatomy.php http://www.balancemotion.com/6-steps-to-correcting-hip-flexor-pain/
Common Hip Conditions
• GT Bursitis• Femoroacetabular impingement• Labral Tears• Osteoarthritis• Piriformis Syndrome
Inspection
InspectionNeurovascular ExamPalpationROMStrengthSpecial Tests
HIP - PHYSICAL EXAMINATION
*ALSO INSPECT GAIT AND ALIGNMENT/ LEG LENGTH
https://patient.info/forums/discuss/sensitive-scar-455022
https://www.youtube.com/watch?v=rmWxIAeVLpc
https://myfaihippain.blogspot.ca/2009/07/hip-arthroscopy-rehab-day-18-hip.html
http://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip
Palpation
• Surface Anatomy• Palpate along bony prominences and soft tissue
landmarks• Make note of points of tenderness
HIP - PHYSICAL EXAMINATION
https://plasticsurgerykey.com/pressure-sores-4/
Range of Motion
• Flexion• Extension• Adduction/Abduction• Internal Rotation• External Rotation
HIP - PHYSICAL EXAMINATION
https://www.peerwell.co/blog/2017/01/13/range-of-motion-after-joint-replacement-surgery/
Strength
Measured out of 5• Flexors• Extensors• Adductors• Abductors
HIP - PHYSICAL EXAMINATION
https://www.researchgate.net/figure/51551969_fig1_Figure-1-HHD-hip-strength-testing-A-Hip-abduction-B-hip-adduction-C-hip
Special Tests
HIP - PHYSICAL EXAMINATION
Impingement test (FADIR)
http://www.hipandkneeadvice.com/index.php/hip-conditions/hip-impingement/
FABER test
https://www.researchgate.net/figure/267630962_fig3_Fig-193-FABER-test
Special Tests
HIP - PHYSICAL EXAMINATION
http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?1/15/1269
Log Roll Straight Leg Raise (SLR)
https://www.aliem.com/2011/08/trick-of-trade-crossed-straight-leg/
Revisiting hip case
- Sami is a 30 y/o olympic rower with bilateral hip pain
- On physical examination:- Normal gait- Normal inspection- Tenderness anteriorly (in groin, bilaterally)- Full flexion, extension, abduction/adduction- Full ER, IR limited to 5 degrees- Grade 5 strength- Negative FABER test, positive impingement test,
Elbow Case
-Marnie is a 76 y/o retired teacher-Presents with left elbow pain x 4 months-Interfering with her hobby of gardening-Improved slightly with topical Voltaren
What else do you want to know?
• Olecranon Bursitis• Medial & Lateral Epicondylitis (Tennis and
Golfer’s Elbow)• Triceps tendonitis• Osteoarthritis• Ulnar neuropathy / Ulnar nerve subluxation
Common Elbow Conditions
Inspection
InspectionNeurovascular ExamPalpationROMStrengthSpecial Tests
ELBOW - PHYSICAL EXAMINATION
https://upload.wikimedia.org/wikipedia/commons/thumb/6/6e/Bursitis_Elbow_WC.JPG/1200px-Bursitis_Elbow_WC.JPG
http://www.sptny.com/blog/wp-content/uploads/2014/02/bicep.png
http://www.eorif.com/sites/default/files/elbow-dislocationlegend.jpg
Palpation
• Surface Anatomy• Palpate along bony
prominences and soft tissue landmarks
• Make note of points of tenderness
ELBOW - PHYSICAL EXAMINATION
http://www.theodora.com/anatomy/images/image1232.gif
Range of Motion
• Flexion• Extension• Supination/Pronation (in
combination with wrist)
ELBOW - PHYSICAL EXAMINATION
https://www.researchgate.net/profile/Miki_Dalmau-Pastor/publication/278696184/figure/fig6/AS:294296830922756@1447177240220/Fig-6-Range-of-motion-of-the-elbow-joint-a-Flexion-extension-movement-provided.png
Strength
Measured out of 5• Flexion• Extension• Supination• Pronation
Grading Muscle Strength /5
Grade 5 – Normal
Grade 4 – Moves limb against resistance and gravity
Grade 3 – Moves limb against gravity
Grade 2 – Moves limb when gravity is eliminated
Grade 1 – Trace of movement with no joint involvement
Grade 0 – No Movement.
ELBOW - PHYSICAL EXAMINATION
https://nervesurgery.wustl.edu/ev/upperextremity/musculocutaneous/Pages/Brachialis.aspx
Special Tests
ELBOW - PHYSICAL EXAMINATION
https://www.tenniselleboog.nl/body_onderzoek.htm
Tinel’s Test at the Elbow
http://www.efortopenreviews.org/content/1/9/316
Positive Hook Test
Negative Hook Test
Special Tests
ELBOW PHYSICAL EXAMINATION
https://userscontent2.emaze.com/images/d5524d57-550e-4946-89d8-823425e780da/9fc1c8c02435a4e84d261f3faa08c0e7.gif
https://i2.wp.com/medisavvy.com/wp-content/uploads/2017/03/Pronator-Teres-Syndrome-Test.jpg?ssl=1
Special Tests
ELBOW PHYSICAL EXAMINATION
https://s3.amazonaws.com/classconnection/753/flashcards/9128753/png/varus_and_valgus_force-1509D775C744A470356.png
Revisiting elbow case
- Marnie is a 76 y/o retired teacher with left elbow pain
- On physical examination:- Inspection reveals slightly enlarged/swollen
olecranon bursa on the left- Palpation: tenderness over lateral epicondyle
and distally into forearm extensor, reproducing patient’s pain
- Stable MCL/LCL, Gr 5 flexion/extension strength- Negative Tinel’s at cubital tunnel- Painful resisted wrist extension