orthopaedic assessment of soft tissue injuries beyond ... · orthopaedic assessment of soft tissue...

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

SOFT TISSUE INJURIES

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

Shoulder Anatomy

http://emedicine.medscape.com/article/1899211-overview

SHOULDER ANATOMY

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


Range of Motion

• Forward Flexion• Abduction/Adduction• Extension

• Internal Rotation• External Rotation• ABER/ ABIR


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.


Special Tests

Hawkin’s Kennedy Test for Impingement

O’Brien’s Test for Labral Pathology


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


http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html

Special Tests for Instability

Sulcus Sign for Inferior Subluxation

Posterior Apprehension Test


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


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


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


Knee Anatomy

http://www.webmd.com/pain-management/knee-pain/picture-of-the-knee#1

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


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





http://www.cram.com/flashcards/hip-knee-exam-2531474

Range of Motion

• Flexion• Extension• Hyperextension• Slight IR/ER (not

typically reported)


https://bonesmart.org/forum/threads/rom-range-of-motion-information.3730/

Strength

Measured out of 5• Quadriceps• Hamstrings


Grade 5 – Normal







http://www.wikidoc.org/index.php/Knee_examination

https://corewalking.com/muscle-testing-check-your-hamstrings/

Special Tests


http://morphopedics.wikidot.com/medial-collateral-ligament-strain-of-the-knee

Special Tests


http://www.aafp.org/afp/2003/0901/p907.html

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


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


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


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


https://plasticsurgerykey.com/pressure-sores-4/

Range of Motion

• Flexion• Extension• Adduction/Abduction• Internal Rotation• External Rotation


https://www.peerwell.co/blog/2017/01/13/range-of-motion-after-joint-replacement-surgery/

Strength

Measured out of 5• Flexors• Extensors• Adductors• Abductors


https://www.researchgate.net/figure/51551969_fig1_Figure-1-HHD-hip-strength-testing-A-Hip-abduction-B-hip-adduction-C-hip

Special Tests


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


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


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


Elbow Anatomy

http://www.braceaccess.com/anatomy-elbow-joint/

• Olecranon Bursitis• Medial & Lateral Epicondylitis (Tennis and

Golfer’s Elbow)• Triceps tendonitis• Osteoarthritis• Ulnar neuropathy / Ulnar nerve subluxation

Common Elbow Conditions

Inspection


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





http://www.theodora.com/anatomy/images/image1232.gif

Range of Motion

• Flexion• Extension• Supination/Pronation (in

combination with wrist)


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


Grade 5 – Normal







https://nervesurgery.wustl.edu/ev/upperextremity/musculocutaneous/Pages/Brachialis.aspx

Special Tests


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

QUESTIONS?

orthopaedic assessment of soft tissue injuries beyond ... · orthopaedic assessment of soft tissue...

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