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Sports Medicine Sports Medicine
WorkshopWorkshop
Shoulder Problem EvaluationShoulder Problem Evaluation
Second most common musculoskeletal Second most common musculoskeletal complaintcomplaint
Difficult joint to examineDifficult joint to examine
Multidirectional range of motion- UNIQUE!Multidirectional range of motion- UNIQUE!
Shoulder injury can affect nearly every Shoulder injury can affect nearly every sport and many daily activitiessport and many daily activities
ObjectivesObjectives
Review pertinent Review pertinent anatomyanatomy
Discuss common Discuss common pathologypathology
Discuss historical Discuss historical clues to diagnosisclues to diagnosis
Select casesSelect cases
Physical exam in small Physical exam in small group discussionsgroup discussions
Bony AnatomyBony AnatomyAnteriorAnterior
Bony AnatomyBony AnatomyAnterior and PosteriorAnterior and Posterior
Radiographic AnatomyRadiographic Anatomy
Where do things go wrong??Fractures
Where do things go wrong??Dislocations and Separations
Dislocations and separations are protected by both “static” and “dynamic” stabilizers…
Where do things go wrong??Dislocations and Separations
Oh, yeah…Arthritis can happen at these joints, too…
Glenohumeral JointGlenohumeral Joint
Shallow (“golf ball sitting on a tee”)Shallow (“golf ball sitting on a tee”)• Inherently unstable (maximizes ROM)Inherently unstable (maximizes ROM)
Static stabilizersStatic stabilizers• glenohumeral ligaments, glenoid labrum and glenohumeral ligaments, glenoid labrum and
capsulecapsule
Dynamic stabilizersDynamic stabilizers• Predominantly rotator cuff musclesPredominantly rotator cuff muscles• Also scapular stabilizersAlso scapular stabilizers
Trapezius, leavator scapulae, serratus anterior, Trapezius, leavator scapulae, serratus anterior, rhomboidsrhomboids
Bony AnatomyBony Anatomy“Static Stabilizers”“Static Stabilizers”
What goes wrong…What goes wrong…Besides separations and dislocations??Besides separations and dislocations??
Instability!!!Instability!!!
LABRUMLABRUM
What goes wrong?Tears and tendonopathies
The Rotator Cuff Muscles“dynamic stabilizers”
The Rotator Cuff Muscles: The Rotator Cuff Muscles: SITSSITS
• SSupraspinatus upraspinatus ABDABD
• IInfraspinatus nfraspinatus ERER
• TTeres minor eres minor ERER• SSupscapularis upscapularis
IRIR
Depress humeral head against glenoid to allow full abduction
Finally…the subacromial space
What can go wrong???
Impingement!!!!!!!
ImpingementImpingement
Other AnatomyOther Anatomy• DeltoidDeltoid• Rotator cuffRotator cuff• Teres majorTeres major
• Latissimus dorsiLatissimus dorsi• BicepsBiceps• Pectoralis musclesPectoralis muscles
Shoulder AnatomyShoulder Anatomy
Don’t forget the scapular stabilizer muscles
So…what causes shoulder pain?
Impingement
Labrum and biceps pathology
A-C joint pathology
Rotator Cuff Injury
InstabilityAmong other
things…
Clinical ExamClinical ExamHistoryHistory
PainPain AcuteAcute ChronicChronic WeaknessWeakness DeformityDeformity
Clinical ExamClinical ExamHistoryHistory
Single eventSingle event
Repetitive overloadRepetitive overload
InstabilityInstability• Does it feel like it’s Does it feel like it’s
going to come out?going to come out?
Catching/LockingCatching/Locking
Clinical ExamClinical ExamHistoryHistory
Sport / OccupationSport / Occupation
Previous injuryPrevious injury
Previous treatmentPrevious treatment
Other joints involvedOther joints involved
DisabilityDisability
Physical Exam: Big 6Physical Exam: Big 6
Inspection Inspection Palpation Palpation Range of MotionRange of Motion StrengthStrength NeurovascularNeurovascular Special TestsSpecial Tests
Special TestsSpecial Tests
ImpingementImpingement
Rotator Cuff Rotator Cuff IntegrityIntegrity
Labrum and BicepsLabrum and Biceps
AC (SC) JointsAC (SC) Joints
InstabilityInstability
Physical Exam
The physical exam will be demonstrated during small group discussions…
Which rotator cuff muscle(s) are responsible for external rotation
1. Supraspinatus
2. Infraspinatus
3. Subscapularis
4. Teres Minor
5. Both 2 and 4
The apex (bottom) of the scapula is at what level of the spine?
1. C72. T33. T74. T125. L4
Case #1Case #1
22-year-old male 22-year-old male rugby player falls rugby player falls onto his right onto his right shoulder while shoulder while being tackledbeing tackled
Severe pain on top Severe pain on top of his right of his right shouldershoulder
Case #1Case #1
Notable deformity Notable deformity over superior over superior shouldershoulder
Painful range of Painful range of motionmotion• Unable to lift right Unable to lift right
arm above waistarm above waist
Special Tests??Special Tests?? Diagnosis???Diagnosis???
Acromioclavicular (A-C) SprainAcromioclavicular (A-C) Sprain
Special TestsSpecial Tests
• Shear TestShear Test
• Cross Arm TestCross Arm Test
• A-C PalpationA-C Palpation
• Resisted ExtensionResisted Extension
• Active compression testActive compression test
Acromioclavicular (A-C) SprainAcromioclavicular (A-C) Sprain
Damage to A-C joint Damage to A-C joint ligamentsligaments
Pain and/or Pain and/or deformity over A-C deformity over A-C jointjoint
Graded I-VIGraded I-VI• I-III usually treated I-III usually treated
non-operativelynon-operatively• IV-VI referred to IV-VI referred to
orthopedic surgeryorthopedic surgery
AC Joint Sprain Treatment
Analgesics, ice prn Sling for as long as needed Physical Therapy
• ROM restoration• Gradual strength exercise• Return to sport activity as
tolerated
Case #2Case #2
24-year-old male 24-year-old male handball playerhandball player
Fell onto his shoulder Fell onto his shoulder after being pushedafter being pushed
Intense painIntense pain Hand is tingling and Hand is tingling and
arm feels like it’s arm feels like it’s hanginghanging
X-raysX-rays
X RAYSX RAYS
DIAGNOSIS???
Shoulder Dislocation/Anterior Shoulder Dislocation/Anterior InstabilityInstability
Humeral head Humeral head dislocates from dislocates from glenoid fossaglenoid fossa
Almost always Almost always anterior (95%)anterior (95%)
Usually traumatic Usually traumatic with injury to with injury to capsule-labrum capsule-labrum complexcomplex
Shoulder Dislocation/Anterior Shoulder Dislocation/Anterior InstabilityInstability
TreatmentTreatment• Reduction of dislocationReduction of dislocation• Protection & rehab, rehab, rehabProtection & rehab, rehab, rehab• Most will have future dislocations Most will have future dislocations
and/or instabilityand/or instability At least 70%!!! (young)At least 70%!!! (young)
• May require surgical May require surgical tightening/repair of the tightening/repair of the capsule/labrum complexcapsule/labrum complex
Special TestsGlenoid Labrum and Instability
Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign
Which of the following structures can be “impinged”?
1 2 3 4
25% 25%25%25%
10
1. Biceps tendon2. Subacromial
Bursa3. Rotator Cuff
Tendons4. All of the above
0
0
30
Case #3Case #3
35-year-old male 35-year-old male tennis playertennis player
Shoulder pain Shoulder pain exacerbated by exacerbated by practicing servespracticing serves
Develops dull, Develops dull, aching pain in right aching pain in right shouldershoulder
SHOULDER PAINSHOULDER PAINPhysical ExamPhysical Exam
Tenderness to palpation anterior Tenderness to palpation anterior shouldershoulder
Pain with abduction starting around Pain with abduction starting around 90 degrees 90 degrees
Unable to lift arm past 120 degreesUnable to lift arm past 120 degrees Pain with forward flexion at 90-120 Pain with forward flexion at 90-120
degreesdegrees Special Tests??? Diagnosis???Special Tests??? Diagnosis???
Shoulder PainShoulder PainPhysical ExamPhysical Exam
Hawkin’s positiveHawkin’s positive
Neer’s positiveNeer’s positive
IMPINGEMENT???IMPINGEMENT???
Impingement as a Clinical SignImpingement as a Clinical Sign
Repetitive overhead Repetitive overhead activitiesactivities
Subacromial bursa Subacromial bursa and/or rotator cuff and/or rotator cuff impinged between impinged between acromion & humerusacromion & humerus
Physical therapy, Physical therapy, activity modification activity modification +/- medications+/- medications
Diagnoses associated with clinical Diagnoses associated with clinical sign of Rotator Cuff Impingement:sign of Rotator Cuff Impingement:
Subacromial bone spurs and / or bursal Subacromial bone spurs and / or bursal hypertrophyhypertrophy
AC joint arthrosis and /or bone spursAC joint arthrosis and /or bone spurs Rotator cuff diseaseRotator cuff disease Superior labral injurySuperior labral injury Glenohumeral instabilityGlenohumeral instability Scapular dyskinesisScapular dyskinesis Biceps tendinopathyBiceps tendinopathy
A diagnostic injection sometimes helps to A diagnostic injection sometimes helps to clarify the diagnosisclarify the diagnosis
Case #4Case #4
45-year-old weight 45-year-old weight lifter lifter
Caught bar as it was Caught bar as it was falling off his shoulderfalling off his shoulder
Sudden painSudden pain Severe weakness left Severe weakness left
shouldershoulder Worse with overhead Worse with overhead
activities; while activities; while sleeping at nightsleeping at night
Pain in anterior lateral Pain in anterior lateral shouldershoulder
Special tests?Special tests?
Case #4Case #4
Drop Arm Test PositiveDrop Arm Test Positive
External Rotation Lag External Rotation Lag Sign positiveSign positive
Weakness with Empty Weakness with Empty Can SignCan Sign
Normal bear hug and Normal bear hug and belly press tests…belly press tests…
Diagnosis?????Diagnosis?????
Rotator Cuff TearRotator Cuff Tear
Supraspinatus tendon most commonSupraspinatus tendon most common
Acute trauma or chronic tendinopathyAcute trauma or chronic tendinopathy
Treatment dependent upon Treatment dependent upon age/activityage/activity• Young, active usually require operative Young, active usually require operative
treatmenttreatment• Older, low-activity usually respond to non-Older, low-activity usually respond to non-
operative treatmentoperative treatment
Case #5Case #5
42-year-old female with dull pain 42-year-old female with dull pain right shoulderright shoulder
Pain is diffuse in naturePain is diffuse in nature Sometimes spreads to between Sometimes spreads to between
shoulder bladesshoulder blades Seems worse at night Seems worse at night
Physical ExamPhysical Exam
Obese, pleasant femaleObese, pleasant female
Diffuse painDiffuse pain
Normal shoulder examNormal shoulder exam
Not able to reproduce pain during examNot able to reproduce pain during exam
What else do you want to do???What else do you want to do???
Shoulder pain isn’t always the Shoulder pain isn’t always the shoulder!!shoulder!!
Get more history…Get more history…
Gall bladder diseaseGall bladder disease Peptic Ulcer DiseasePeptic Ulcer Disease Cervical radiculopathyCervical radiculopathy Cardiac ischemiaCardiac ischemia Pulmonary conditionsPulmonary conditions
• ie Pancoast’s tumor, Pneumoniaie Pancoast’s tumor, Pneumonia
In the human body, which is the most incredible joint?
1 2 3 4 5
20% 20% 20%20%20%1. PIP2. Knee3. Ankle4. Shoulder5. None of the
above
Case #6Case #6
40-year-old male40-year-old male
Recently shoveled Recently shoveled 16” of snow16” of snow
Can hardly lift left Can hardly lift left arm due to painarm due to pain
Special Tests? Special Tests? Diagnosis?Diagnosis?
Biceps TendonopathyBiceps Tendonopathy
Speed TestSpeed Test
Yergason TestYergason Test Direct palpationDirect palpation
Biceps TendonopathiesBiceps Tendonopathies
Repetitive overhead Repetitive overhead activity activity
Repetitive forearm Repetitive forearm flexion/supinationflexion/supination
Difficult to discern from Difficult to discern from rotator cuff tendinopathy rotator cuff tendinopathy or impingementor impingement
ConclusionConclusion
Shoulder injuries are common.Shoulder injuries are common.
Knowledge of the anatomy is crucial Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis.to correct patho-anatomic diagnosis.
Impingement is a clinical sign, not a Impingement is a clinical sign, not a diagnosis.diagnosis.
Don’t forget about medical causes.Don’t forget about medical causes.
Physical ExamPhysical ExamInspectionInspection
Front & backFront & back Height of Height of
shoulder and shoulder and scapulaescapulae
Muscle atrophy, Muscle atrophy, asymmetryasymmetry
Physical ExamPhysical Exam Range of MotionRange of Motion
Abduction 0-180Abduction 0-180oo
Physical ExamPhysical Exam Range of MotionRange of Motion
Forward flexion: Forward flexion: • 00oo – 180 – 180oo
Physical ExamPhysical Exam Range of MotionRange of Motion
ExtensionExtension• 00oo – 40 to 60 – 40 to 60oo
Physical ExamPhysical Exam Range of MotionRange of Motion
Internal rotationInternal rotation• T5 segmentT5 segment
External rotationExternal rotation• 80-9080-90oo
Physical ExamPhysical Exam StrengthStrength
Empty can testEmpty can test• 3030oo angle angle• Steady downward pressureSteady downward pressure• Tests supraspinatus strength and painTests supraspinatus strength and pain
Physical ExamPhysical Exam StrengthStrength
Resisted external Resisted external rotationrotation• Tests infraspinatus, Tests infraspinatus,
teres minor teres minor strengthstrength
Physical ExamPhysical Exam Strength of SubscapularisStrength of Subscapularis
Liftoff testLiftoff test Belly press Belly press testtest
Cross-Arm Adduction TestCross-Arm Adduction Test
AC joint pathologyAC joint pathology Arm flexed to 90Arm flexed to 90°° Hyperadduct arm Hyperadduct arm
across body as far across body as far as possibleas possible
Pain in AC = (+) Pain in AC = (+) testtest
A-C Shear TestA-C Shear Test
Interlock fingers Interlock fingers with hand on distal with hand on distal clavicle and spine clavicle and spine of scapulaof scapula
Pain in A-C joint Pain in A-C joint when hands when hands squeezed together squeezed together = (+) test= (+) test
Sulcus SignSulcus Sign
Inferior instabilityInferior instability Arm relaxed in Arm relaxed in
neutral position, neutral position, pull downward at pull downward at elbowelbow
(+) test = sulcus at (+) test = sulcus at infra-acromial area infra-acromial area • compare to compare to
unaffected sideunaffected side
Apprehension TestApprehension Test
Anterior instabilityAnterior instability Shoulder at 90Shoulder at 90°°
abducted, slight abducted, slight anterior pressure & anterior pressure & External rotationExternal rotation
(+) test = (+) test = dislocation dislocation apprehensionapprehension• some false (+)some false (+)
Relocation TestRelocation Test
Perform after Perform after positive positive apprehension testapprehension test
Apply post force Apply post force over humeral head over humeral head during external during external rotation (ER)rotation (ER)
(+) test = (+) test = increased ER increased ER tolerancetolerance
Load & Shift TestLoad & Shift Test
Test for multidirectional instabilityTest for multidirectional instability Grasp humeral head, slide anteriorly and Grasp humeral head, slide anteriorly and
posteriorly while securing rest of shoulderposteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded (+) if greater than 50% displacement (graded
1-3)1-3)
Impingement SignsImpingement Signs
Hawkins Neer
Drop Arm TestDrop Arm TestSuggestive of Rotator Cuff TearSuggestive of Rotator Cuff Tear
Passive abduction Passive abduction to 90to 90°°
Instruct patient to Instruct patient to slowly lower armslowly lower arm
At 90At 90°° abducted abducted arm will suddenly arm will suddenly drop, may need to drop, may need to add slight pressureadd slight pressure
(+) drop = (+) test(+) drop = (+) test
Speed’s TestSpeed’s TestBiceps TendinopathyBiceps Tendinopathy
Long head of biceps Long head of biceps tendonitistendonitis
Fwd flex to 90Fwd flex to 90°°, abd , abd 1010°°, full supination, full supination
Apply downward Apply downward force to distal armforce to distal arm
Pain = (+) testPain = (+) test• weakness w/o weakness w/o
pain = muscle pain = muscle weakness or weakness or rupturerupture
O’Brien’s Active CompressionO’Brien’s Active CompressionSLAP lesion (Superior Labrum Antero-Posterior)SLAP lesion (Superior Labrum Antero-Posterior)
Labral/AC Labral/AC pathologypathology
Arm flexed to 90Arm flexed to 90°°, , elbow extended, elbow extended, adduct 10-15adduct 10-15°°, , resist downward resist downward forceforce
+ if AC pain or + if AC pain or internal pain/clickinternal pain/click
O’Brien’s Active CompressionO’Brien’s Active CompressionSLAP lesionSLAP lesion
Supination should Supination should be pain free be pain free (decreased pain)(decreased pain)
Crank TestCrank TestLabral injuryLabral injury
Glenoid labrum tearGlenoid labrum tear Abduct arm to 160Abduct arm to 160°,°,
pt is supine or pt is supine or upright, elbow upright, elbow secured with one secured with one hand axial load at hand axial load at shoulder with othershoulder with other
(+) if audible/painful (+) if audible/painful catch/grind is notedcatch/grind is noted
Knee ProblemsKnee Problems
Anatomy ReviewAnatomy Review
FemurFemur• Medial & lateralMedial & lateral
CondylesCondyles EpicondylesEpicondyles
• Trochlear grooveTrochlear groove• Intercondylar notchIntercondylar notch
PatellaPatella• Superior pole (base)Superior pole (base)• Inferior pole (apex)Inferior pole (apex)• Medial & lateral facetsMedial & lateral facets
TibiaTibia• Medial & lateralMedial & lateral
CondylesCondyles• Gerdy’s tubercleGerdy’s tubercle• Pes anserine areaPes anserine area• Tibial tuberosityTibial tuberosity• Tibial plateauTibial plateau• Tibial spinesTibial spines
FibulaFibula• HeadHead• NeckNeck
Anatomy – Major Ligaments & TendonsAnatomy – Major Ligaments & Tendons Quadriceps tendonQuadriceps tendon
Patellar tendonPatellar tendon
Medial & lateral patellar Medial & lateral patellar retinaculuaretinaculua
MCLMCL LCLLCL
ACL and PCLACL and PCL
Iliotibial band (ITB)Iliotibial band (ITB)
Anatomy – Menisci of the KneeAnatomy – Menisci of the Knee
Medial meniscusMedial meniscus Lateral meniscusLateral meniscus
• Meniscal ligamentsMeniscal ligaments• Functions of the Functions of the
meniscimenisci
Meniscal zonesMeniscal zones• White-whiteWhite-white• Red-whiteRed-white• Red-redRed-red
Knee Exam OverviewKnee Exam Overview
InspectionInspection PalpationPalpation Range of MotionRange of Motion StrengthStrength NeurovascularNeurovascular Special TestsSpecial Tests
Case 1 – Medial Right Knee PainCase 1 – Medial Right Knee Pain
16yo HS soccer 16yo HS soccer player, previously player, previously healthyhealthy
Tackled from right Tackled from right side while runningside while running
Immediate onset of Immediate onset of medial jt line painmedial jt line pain
Delayed onset local Delayed onset local medial edema, medial edema, stiffnessstiffness
Able to bear weight Able to bear weight
Key Questions in the HistoryKey Questions in the History
Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Location and level of pain?Location and level of pain? Able to walk?Able to walk? Mechanical Symptoms? (Locking, Mechanical Symptoms? (Locking,
popping, catching?)popping, catching?) Associated instability?Associated instability? Swelling?Swelling? Previous injuries or surgeries?Previous injuries or surgeries?
Case 1 - ExamCase 1 - Exam
Inspection: Mild medial knee edemaInspection: Mild medial knee edema Palpation: + ttp medial kneePalpation: + ttp medial knee ROM: can’t bend >80dROM: can’t bend >80d Strength: mildly decreasedStrength: mildly decreased Neurovascular: normalNeurovascular: normal Special tests:Special tests:
• Neg Lachman, Anterior Drawer, McMurray, Neg Lachman, Anterior Drawer, McMurray, varus stressvarus stress
+ mild increased gap on valgus stress + mild increased gap on valgus stress (compared to left) with good endpoint(compared to left) with good endpoint
Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test
Special Tests - PCL InjurySpecial Tests - PCL Injury Posterior Drawer TestPosterior Drawer Test
Sag SignSag Sign
Quad-Active TestQuad-Active Test
Varus/Valgus stress for Varus/Valgus stress for LCL and MCL InjuryLCL and MCL Injury
Features that should prompt an xray after acute knee injury include:
Unable to
bear weight
Can’t flex >
90d
Patella
TTP
Fibular h
ead TTP
Age <18 or >55
All of t
he above
17% 17% 17%17%17%17%1. Unable to bear
weight2. Can’t flex >90d3. Patella TTP4. Fibular head
TTP5. Age <18 or >556. All of the above
5 Ottawa Knee Rules5 Ottawa Knee Rulesi.e. When to order a knee xray after acute injuryi.e. When to order a knee xray after acute injury
Age > 55 or < 18Age > 55 or < 18 Unable to walkUnable to walk TTP on PATELLATTP on PATELLA TTP on FIBULAR HEADTTP on FIBULAR HEAD Unable to flex 90 degUnable to flex 90 deg
Case 1 - ImagingCase 1 - Imaging
Case 1 – Differential DiagnosisCase 1 – Differential DiagnosisMore LikelyMore Likely Less LikelyLess Likely
Meniscal TearMeniscal Tear Ligamentous InjuryLigamentous Injury
• Which ligament?Which ligament? ACLACL PCLPCL MCLMCL LCLLCL
Muscle StrainMuscle Strain
FractureFracture Patellofemoral PainPatellofemoral Pain PlicaPlica
MCL SprainMCL Sprain
What grade of sprain is likely present of the MCL?
25%
25%
25%
25% 1. Grade 1: no laxity, but hurts
2. Grade 2: mild laxity, still intact
3. Grade 3: complete tear
4. Grade 4: hurts like *^%*
MCL Sprain
Treatment?Treatment?• RICERICE• Relative RestRelative Rest• Hinge Brace only if unstable on examHinge Brace only if unstable on exam• Achieve full ROMAchieve full ROM• Progressive StrengtheningProgressive Strengthening• Neuromuscular Control (Balance Neuromuscular Control (Balance
exercises)exercises)• Functional Exercises (Sport-specific)Functional Exercises (Sport-specific)
Case 2Case 2
56 yo retired Army LTC56 yo retired Army LTC 15 years worsening L>R knee pain15 years worsening L>R knee pain Former parachutist, no specific Former parachutist, no specific
traumatrauma No previous knee surgeriesNo previous knee surgeries Stiffness worse in morningStiffness worse in morning Pain is worse with activity, better Pain is worse with activity, better
with restwith rest
Case 2 – Key QuestionsCase 2 – Key Questions
Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where/how bad is pain?Where/how bad is pain? Mechanical Symptoms? Mechanical Symptoms?
(Locking, popping, (Locking, popping, catching?)catching?)
Associated instability?Associated instability? Swelling?Swelling? Previous injuries or Previous injuries or
surgeries?surgeries? What makes it worse?What makes it worse? What makes it better?What makes it better?
Insidious OnsetInsidious Onset ChronicChronic Difficult to localize; mildDifficult to localize; mild NoNo
NoneNone OccasionalOccasional Lots of “Bad Landings” No Lots of “Bad Landings” No
surgerysurgery ActivityActivity RestRest
Case 2 – Physical ExamCase 2 – Physical Exam
Inspection: Inspection: • Genu varusGenu varus• Bony enlargement at Med/Lat joint linesBony enlargement at Med/Lat joint lines
Palp: Posterior medial joint line ttpPalp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild ROM: Decreased flexion, 110 deg, mild
crepituscrepitus Strength: normalStrength: normal Neurovascular: normalNeurovascular: normal Special Tests: no ligamentous laxity, neg Special Tests: no ligamentous laxity, neg
meniscal testsmeniscal tests
Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries Joint line tendernessJoint line tenderness
McMurray TestsMcMurray Tests
Thessaly testThessaly test
Bounce-home testBounce-home test
Full SquatFull Squat
Case 2 – Plain FilmsCase 2 – Plain Films
Joint space narrowing
Subchondral Sclerosis
Osteophytes
Subchondral Cysts
What is your diagnosis?What is your diagnosis?
Menisc
al tear
Plica sy
ndrome
Oste
oarthriti
s
Bone tumor
25% 25%25%25%1.1. Meniscal tearMeniscal tear
2.2. Plica syndromePlica syndrome
3.3. OsteoarthritisOsteoarthritis
4.4. Bone tumorBone tumor
OsteoarthritisOsteoarthritis
Nonpharmacologic Nonpharmacologic Treatment:Treatment:• Nonpainful aerobic Nonpainful aerobic
activityactivity• Weight lossWeight loss• Physical TherapyPhysical Therapy
Improve ROM, increase Improve ROM, increase strengthstrength
• BracingBracing
Pharmacologic Pharmacologic Treatment:Treatment:• APAPAPAP• SupplementsSupplements
Glucosamine and Glucosamine and ChondroitinChondroitin
• NSAIDs, COX-2’sNSAIDs, COX-2’s• TramadolTramadol• ViscosupplementationViscosupplementation• Intrarticular SteroidsIntrarticular Steroids
Case 3Case 3
31 year old female, L knee pain31 year old female, L knee pain Recreational runnerRecreational runner Localizes pain to front of kneeLocalizes pain to front of knee No trauma, insidious onsetNo trauma, insidious onset Localizes pain “around kneecap”Localizes pain “around kneecap” Worse with stairsWorse with stairs Worse after prolonged sittingWorse after prolonged sitting Knee occasionally “gives out”Knee occasionally “gives out”
Case 3 – Key QuestionsCase 3 – Key Questions
Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? Mechanical Mechanical
Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)
Associated instability?Associated instability? Swelling?Swelling? Previous injuries or Previous injuries or
surgeries?surgeries? What makes it worse?What makes it worse? What makes it better?What makes it better?
Insidious OnsetInsidious Onset ChronicChronic Anterior kneeAnterior knee No, but sometimes No, but sometimes
gives outgives out
NoneNone NoneNone NoneNone Running, StairsRunning, Stairs Multiple days of restMultiple days of rest
Physical Exam
Inspection: mild genu valgus Palpation: TTP lateral > medial patellar
facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests:
• + patellar grind• Decreased patellar glide• Inflexible hamstrings (Popliteal angle)
Patellofemoral Joint ExamPatellofemoral Joint Exam
Patellofemoral Joint ExamPatellofemoral Joint Exam
Patellar Grind TestPatellar Grind Test
Case 3 – Plain FilmsCase 3 – Plain Films
AP
Lateral
Case 3 – Plain FilmsCase 3 – Plain Films
Tunnel
Sunrise
What’s your diagnosis?
Patella
r tendinopath
y
Patella
r insta
bility
Patello
femoral sy
ndrome
Plica sy
ndrome
25% 25%25%25%1. Patellar tendinopathy
2. Patellar instability3. Patellofemoral
syndrome4. Plica syndrome
Patellofemoral SyndromePatellofemoral Syndrome
Treatment:Treatment:• Relative rest; non-painful aerobicsRelative rest; non-painful aerobics• Physical TherapyPhysical Therapy
Improve Quad/Hamstring flexibilityImprove Quad/Hamstring flexibility Quad, Hip abductor strengtheningQuad, Hip abductor strengthening Core strengtheningCore strengthening
• Patellar stabilization brace/tapingPatellar stabilization brace/taping• Foot orthoticsFoot orthotics• Surgery (last-ditch effort)Surgery (last-ditch effort)
Case 4Case 4
34 yo Army MAJ training for 34 yo Army MAJ training for 11stst marathon marathon
Atraumatic onset of R Atraumatic onset of R lateral knee pain 1 week lateral knee pain 1 week ago after 10 mile runago after 10 mile run
Sharp burning painSharp burning pain Better with rest, returns Better with rest, returns
with runningwith running
Case 4 – Key QuestionsCase 4 – Key Questions
Mechanism of Injury?Mechanism of Injury? Acute or Chronic?Acute or Chronic? Where is the pain?Where is the pain? Mechanical Mechanical
Symptoms? (Locking, Symptoms? (Locking, popping, catching?)popping, catching?)
Associated instability?Associated instability? Swelling?Swelling? Previous injuries or Previous injuries or
surgeries?surgeries? What makes it worse?What makes it worse? What makes it better?What makes it better?
Insidious OnsetInsidious Onset AcuteAcute Lateral kneeLateral knee No, but sometimes No, but sometimes
gives outgives out
NoneNone NoneNone NoneNone RunningRunning Multiple days of restMultiple days of rest
Physical Exam
Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests:
• + Noble test• Tight on Ober test
Ober testOber test Noble testNoble test
What’s your diagnosis?
Oste
oarthriti
s
Menisc
al tear
Iliotibial b
and syndro
me
LCL s
prain
25% 25%25%25%1. Osteoarthritis2. Meniscal tear3. Iliotibial band
syndrome4. LCL sprain
Iliotibial Band SyndromeIliotibial Band Syndrome
Treatment:Treatment:• Ice massage, pain medsIce massage, pain meds• Relative Rest; nonpainful activityRelative Rest; nonpainful activity• Physical TherapyPhysical Therapy
Specific ITB stretchesSpecific ITB stretches Hip abductor strengtheningHip abductor strengthening Core strengthening (Gluteus Medius)Core strengthening (Gluteus Medius)
• Slow return to activitySlow return to activity• Extrinsic factors: shoes, running surface, Extrinsic factors: shoes, running surface,
training errorstraining errors
What the heck is a Plica?
Congenital th
ickening of...
Redundant menisc
us
Loose
piece of in
tra-arti
...
Figm
ent of m
y imagin
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25% 25%25%25%1. Congenital thickening of joint capsule
2. Redundant meniscus3. Loose piece of intra-
articular cartilage4. Figment of my
imagination
Plica Syndrome?
Special Tests - ACL InjurySpecial Tests - ACL Injury Lachman TestLachman Test
• Knee flexed to 15-30 degreesKnee flexed to 15-30 degrees• Stabilize distal femurStabilize distal femur• Anteriorly translate tibia on Anteriorly translate tibia on
femurfemur• Watch & feel for amount of Watch & feel for amount of
translation & end pointtranslation & end point
Pivot ShiftPivot Shift
Special Tests - PCL InjurySpecial Tests - PCL Injury Posterior Drawer TestPosterior Drawer Test
• Knee flexed to 90 degreesKnee flexed to 90 degrees• Posteriorly translate tibia on Posteriorly translate tibia on
femurfemur• Watch & feel for amount of Watch & feel for amount of
translation & end pointtranslation & end point
Sag SignSag Sign• Knees flexed, quads relaxedKnees flexed, quads relaxed
compare both sidescompare both sides• Look for tibial posterior “sag” Look for tibial posterior “sag”
relative to femurrelative to femur
Quad-Active TestQuad-Active Test• Knee flexed; hamstrings Knee flexed; hamstrings fullyfully
relaxedrelaxed• Slide foot along table (quad Slide foot along table (quad
active)active)• Observe for anterior relocationObserve for anterior relocation
Special Tests - MCL InjurySpecial Tests - MCL Injury
Valgus Stress TestingValgus Stress Testing• Knee flexed to 30 degreesKnee flexed to 30 degrees
Relax ACL/PCL & joint Relax ACL/PCL & joint capsulecapsule
• Valgus stress applied to kneeValgus stress applied to knee
• Look and feel for translation Look and feel for translation and endpointand endpoint
• Compare to uninjured sideCompare to uninjured side
• May repeat with knee in full May repeat with knee in full extensionextension
Special Tests - LCL InjurySpecial Tests - LCL Injury
Varus Stress Varus Stress TestingTesting• Same test as Same test as
valgus stress valgus stress testingtesting
• Except applying Except applying a varus stress a varus stress insteadinstead
• LCL, IT band, & LCL, IT band, & PLC are testedPLC are tested
Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries Joint line tendernessJoint line tenderness
Full SquatFull Squat
McMurray TestsMcMurray Tests
Thessaly testThessaly test
Bounce-home testBounce-home test
McMurray test for McMurray test for Meniscal injuryMeniscal injury
Test Med and Lat meniscus Test Med and Lat meniscus separatelyseparately
3 concurrent maneuvers:3 concurrent maneuvers:• GrindGrind it (Rotate tibia it (Rotate tibia
AWAY from it)AWAY from it)• CrunchCrunch it (varus or it (varus or
valgus)valgus)• PinchPinch it (flex/extend knee) it (flex/extend knee)
Positive: Painful “pop”Positive: Painful “pop”
Special Tests - Meniscal InjuriesSpecial Tests - Meniscal Injuries
Thessaly TestThessaly Test• Pt stands on Pt stands on
affected legaffected leg• Knee bent at 20 Knee bent at 20
degreesdegrees• Examiner holds pt’s Examiner holds pt’s
hands and rotates hands and rotates pt to both sidespt to both sides
Meniscal grindMeniscal grind
• Positive test: pain, Positive test: pain, painful click.painful click.
Anterior Knee ExamAnterior Knee Exam
Palpation of patellar Palpation of patellar facetsfacets
Glide and lift patella Glide and lift patella medially & laterallymedially & laterally
Palpate undersurface Palpate undersurface of patella for of patella for tendernesstenderness
Patellar ExamPatellar Exam
• Patellar GlidePatellar Glide Knee in extension, relaxedKnee in extension, relaxed Medial & lateral patellar Medial & lateral patellar
displacementdisplacement• Measured in quadrantsMeasured in quadrants
Normal: 1-2 quadrantsNormal: 1-2 quadrants Patellar ApprehensionPatellar Apprehension
Lateral patellar displacementLateral patellar displacement
patient apprehensionpatient apprehension
or guardingor guarding
Anterior Knee ExamAnterior Knee Exam
Patellar Grind TestPatellar Grind Test
Knee 10 deg flexionKnee 10 deg flexion Glide patella distally, Glide patella distally,
and firmly compress and firmly compress patella against patella against trochlear groovetrochlear groove
Active quadriceps Active quadriceps contraction contraction pain pain
Special Tests – Ober’s TestSpecial Tests – Ober’s Test
Lateral decubitus with Lateral decubitus with testing side up, testing testing side up, testing knee flexedknee flexed
Adduct and fully flex hip Adduct and fully flex hip Abduct, externally rotate, Abduct, externally rotate, & extend hip& extend hip
Slowly release support Slowly release support against gravity from leg, against gravity from leg, allowing gravity to take leg allowing gravity to take leg towards tabletowards table
Positive test: leg remains Positive test: leg remains abducted despite abducted despite examiner releasing legexaminer releasing leg
Special TestsSpecial Tests
Noble’s testNoble’s test• Palpate lateral Palpate lateral
femoral condylefemoral condyle• Flex and Extend Flex and Extend
KneeKnee• + Test is pain at + Test is pain at
site of palpationsite of palpation