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MSK Special Tests

Terms in this set (103)

What special maneuvers are used when evaluating shoulder pain (3)?
•Cross over test
•Apleys scratch test
•Apprehension test
What special maneuvers are used when evaluating the rotator cuff (5)?
•Drop arm test
•Empty Can Test
•Hawkin's impingement
•Infraspinatus test
•Neer impingement
What special maneuvers are used when evaluating the hand (4)?
•Tinel's sign
•Phalen's sign
•Finklestein's test
•Rheumatoid & OA
What special maneuvers are used when evaluating the knee (9)?
•Patellar palpation
•Palpation for bulge sign
•Ballottement
•Valgus/abductor stress tes
•Varus/adductor stress tes
•McMurray Tes
•Anterior drawer test
•Posterior drawer test
•Lachmans Test
What special maneuvers are used when evaluating back pain (2)?
•Straight leg raise test
•FABER test
What are the muscles of the rotator cuff?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What movement does the following muscle do?

Subscapularis
Internal rotation
What movement does the following muscle do?

Supraspinatus
Elevation
What movement does the following muscle do?

Infraspinatus
External rotations
What movement does the following muscle do?

Teres Minor
External rotation
When inspecting a pts shoulder for pain or injury, what is done 1st?
-Observe shoulder movement with intro handshake
-Laying-down of a magazine, or removal of a shirt/gown
What should you do while taking hx?
-Observe restrictions or favoring of an arm
-Help pt relax so natural motions can be assessed
PE should include:
-Inspection
-Palpation
-ROM
*compare bilaterally
What is MC seen with rotator cuff injuries?
Injury or impingement
What is important when assessing rotator cuff injuries?
Occupations or activity with shoulder over use, or position arm overhead
(exp. painter, baseball)
How is the Crossover Test done?
-Pt sitting or standing
-Adduct arm across the chest
What is the Crossover Test assessing?
Shoulder pain
When is the Crossover Test positive & what does that indicate?
Positive: pain w/ adduction indicates:
-Arthritis & inflammation of AC joint
How is the Drop Arm Test done?
-Pt abducts arm to shoulder level
-Then lowers slowly
When is the Drop Arm Test positive & what does that indicate?
Used to assess possible tears of the supraspinatus tendon
Positive: unable to hold arm at shoulder level or cannot control lowering
-Rotator cuff tear
What is the Drop Arm Test assessing?
Rotator cuff
How is the Empty Can Test done?
-Elevate arm to 90 degrees & internally rotate w/ thumbs downward as if emptying a can
-Ask pt to resist downward pressure on the arms
When is the Empty Can Test positive & what does that indicate?
Positive: weakness of the supraspinatus muscle
-Rotator cuff tear
What is the Empty Can Test assessing?
Rotator cuff
How is the Infraspinatus Test done?
-Pt places arms at side
-Elbows flexed at 90 degrees w/ thumbs turned up
-Provide resistance as pt presses outward
When is the Infraspinatus Test positive & what does that indicate?
Positive: weakness of the infraspinatus muscle
-Rotator cuff tear
-Bicipital tendinitis
What is the Infraspinatus Test assessing?
Rotator cuff
What is the primary action of the subscapularis muscle?
Internal rotation
How is the Push Off Test done?
Tests integrity of the subscapularis
-Pt puts hand of affected side behind back
-Provide resistance
-Pt asked to push off hand from the back
When is the Push Off Test positive & what does that indicate?
Positive: if pain or weakness present
How is the Apley Scratch Test done?
Pt touches opposite scapula using motion shown
1. Abduction & external rotation
2. Adduction & internal rotation
When is the Apley Scratch Test positive & what does that indicate?
Positive: if pain or difficulty
-Adhesive capsulitis (frozen shoulder)
How is the Neer's Impingement Test done?
-Press on scapula to prevent motion
-Raise pts arm with other
(Raising hand in class: ME ME)
When is the Neer's Impingement Test positive & what does that indicate?
Positive: rotator cuff inflammation
-Rotator cuff tear
-Subacromial impingement
What does the Neer's Impingement Test assess?
Rotator cuff
How is the Hawkins Impingement Test done?
-Flex pts shoulder & elbow at 90 degrees with palm facing down
-Place one hand on arm & one on forearm & internally rotate
When is the Hawkins Impingement Test positive & what does that indicate?
Positive: rotator cuff inflammation
-Rotator cuff tear
-Sub acromial impingement
What is the Hawkins Impingement Test assessing?
Rotator cuff
How is the Apprehension Test done?
-Pt holds arm at 90 degrees abduction with elbow at 90 degrees flexion
-Stand behind pt, stabilizing post shoulder w/ hand & hold wrist with other
-Ask pt to resist post motion of wrist as you pull backward
When is the Apprehension Test positive & what does that indicate?
Positive: perception of impending dislocation
What does the Apprehension Test assess?
Shoulder dislocation
What is Carpal Tunnel Syndrome?
Pt c/o numbness or tingling in the 1st three digits & the lateral aspect of the 4th digit of hand
Which 2 tests are performed in an attempt to reproduce symptoms?
-Phalen's Sign
-Tinel's Sign
How is the Phalen's Test done?
-1 min acute wrist flexion against resistance
-Inverse praying position
-Place ea hand dorsum against ea other hold for
60-90 sec
When is the Phalen's Test positive & what does that indicate?
Positive: numbness & tingling in media nerve
-Carpal tunnel syndrome
How is the Tinel's Test done?
-Slightly tap over median nerve in the carpal tunnel
-Tap over volar carpal ligament
When is the Tinel's Test positive & what does that indicate?
Positive: numbness in the media nerve
-Carpel Tunnel syndrome
What type of injury can result in a scaphoid bone fracture?
Falling on outstretched hand
How would you evaluate the wrist for a scaphoid fracture?
Palpate distal radius & ulna at the articulation with the carpal bones
*palpate anatomic snuff box
What findings can indicate a possible scaphoid fracture?
Wrist pain when palpating snuff box
How is the Finklestein Test done?
-Examiner braces wrist in ulnar deviation
-Examiner passively flexes thumb across palm
When is the Finklestein Test positive & what does that indicate?
Positive: pain with flexion over dorsal thumb; chronic pain over snuff box
-DeQuervain disease
What findings are commonly seen with Rheumatoid Arthritis (RA)?
Ulnar deviation of fingers
What is Boutonniere Deformity?
Pathologic flexion at the proximal interphalangeal (PIP) joint & hyperextension at the distal interphalangeal (DIP) joint
Boutonniere Deformity involves flexion of the ______ joint & hyperextension of the _______ joint.
PIP
DIP
What is Swan Neck Deformity?
Pathologic flexion at the distal interphalangeal (DIP) joint & hyperextension at the proximal interphalangeal (PIP) joint
Swan Neck Deformity involves flexion of the ______ joint & hyperextension of the _______ joint.
DIP
PIP
(The swam is trying to DIP- dip first = flexion)
What is Osteoarthritis?
Bony enlargement of the PIP & DIP joints
-also assoc with arthritis
Heberden's nodes are found with ______.
OA
Bouchard's nodes of the PIP are found with ______.
OA.
T/F: Knee pain can present with or without trauma.
True
What is knee pain often assoc with?
Swelling, noises (popping, clicking), instability
Knee instability MC reflects what type of injury?
Ligamentous injury
When a pt presents with knee pain or injury, what can help the provider to obtain an accurate diagnosis?
Detailed exam incl. symptom location, presence of edema, recognition of ROM limitation, & instability
-structural testing should be performed
Knee Pain Localization Chart
How is the Bulge Sign Test done?
-Extend knee & place hand above knee
-Apply pressure to the suprapatellar notch
-Displace or milk fluid downward & medial
-Tap on lateral margin
When is the Bulge Sign Test positive & what does that indicate?
Positive: fluid wave on the medial side
-Minor effusion
How is the Ballottement Test performed?
-Extend knee
-Compress suprapatellar pouch
-Push patellar against femur
When is the Ballottement Test positive & what does that indicate?
Positive: fluid returns the suprapatellar pouch
-Large effusion
How is the Knee - Ballottement Test done?
-Pt lying or seated with legs extended at knee
-Beginning at mid-thigh, attempt to milk fluids from tissues distally several times stopping just proximal to patella with ea pass
-With last milking, rapidly tap patella posteriorly
When is the Knee - Ballottement Test positive & what does that indicate?
Positive: patella will depress downward & bob back up due to excessive fluid
-Fluid within joint space
How is the Varus/Adductor Stress Test done?
-Pt supine w/ knee slight flexed
-Place hand on medial aspect of knee
-Place other hand on lateral ankle
-Push laterally on knee & medially on ankle
When is the Varus/Adductor Stress Test positive & what does that indicate?
Positive: pain in lateral joint
-Lateral collateral ligament
(Varus- Lateral)
How is the Valgus/Abductor Stress Test done?
-Pt supine w/ knee slight flexed
-Place hand on lateral aspect of knee
-Place other hand on medial ankle
-Push medially on knee & laterally on ankle
When is the Valgus/Abductor Stress Test positive & what does that indicate?
Positive: pain in the medial joint
-Medial collateral ligament
(Valgus- Medial)
How is the Anterior Drawer Test done?
Pt supine
-Hips flexed
-Knee flexed at 90 degrees
Student should sit on ankle to stabilize
Place hand around tibia & then attempt to pull tibia forward
When is the Anterior Drawer Test positive & what does that indicate?
Positive: forward jerk
-ACL laxity --> rupture
How is the Posterior Drawer Test done?
Pt supine
-Hips flexed
-Knee flexed at 90 degrees
Student should sit on ankle to stabilize
Place hand around tibia & then attempt to push tibia backward
When is the Posterior Drawer Test positive & what does that indicate?
Positive: displacement of the tibia posterior
-PCL laxity
How is the Lachman's Test done?
-Place knee 15 degrees of flexion & external rotation
-Grasp distal femur lateral side
-Grasp proximal tibia on medial side
-Pull proximal tibia anteriorly -Push femur posteriorly
When is the Lachmans Test positive & what does that indicate?
Positive: degree of forward excursion
-ACL rupture
How is McMurray's Test performed when assessing the medial meniscus?
-Pt supine
-Grasp heel with palm & flex knee
For Medial Meniscus:
-Place hand at lateral joint line, apply valgus (ABD) stress & externally rotate foot while extending knee & feel for click or pop assoc with pain
How is McMurray's Test performed when assessing the lateral meniscus?
-Pt supine
-Grasp heel with palm & flex knee
For Lateral Meniscus:
-Place hand at medial joint line, apply vargus (ADD) stress & internally rotate foot while extending knee & feel for click or pop assoc with pain
How is the Apley Grind Test done?
-Pt prone with knee flexed to 90 degrees, perpendicular to floor
-Place one hand btwn table & knee
-Hold mid-foot with other hand
-Exert pressure through foot toward knee while internally & externally rotating foot
-Feel for grinding or popping
When is the Apley Grind Test positive & what does that indicate?
Positive: grinding or popping
-Possible meniscal tear
T/F: Lower back pain always indicatives a serious problem.
FALSE
*First of all, the word ALWAYS does not exist in medicine!!!
-Can be serious, acute or chronic condition requiring conscientiousness in care
-Can also be fictitious
How is the Straight Leg Raise Test done?
-Pt supine
-Stand at end of exam table & place both hands under pt's heels
-Ask pt to raise one leg at a time w/o bending knee
-As pt lifts R leg, you should feel left heel pressing down into hand indicating a true effort in lifting leg
When is the Straight Leg Raise Test positive & what does that indicate?
Positive: ↑ pain as leg is raised
-Bulging or herniated disc should be considered
-Fictitious disorder: no pressure appreciated
(pain occurs at 30-40 degrees of leg elevation)
If fictitious disorder is suspected, what test should be performed next?
Seated SLR
How is a Seated SLR Test done?
-Pt seated, legs over side of exam table
-Advise pt that you will now be checking lower leg
-Palpate ankle with leg hanging loosely & ask pt if any pain is experienced
-If pt supine, leg would now be at 90 degrees of hip flexion or a full SLR
If pt tolerates the Seated SLR w/o pain but complains of pain with supine SLR, what should be suspected?
Malingering
-SLR testing can also be performed passively, with provider lifting pt's leg
What is the SLR Test used to assess?
Lumbrosacral radiculopathy
-Indicates severe impingement
-Almost always due to large disk herniation
With Spinal Stenosis pain is worse with extension of back or when leaning forward?
When back is extended
-remember old folks bending over with their grocery cart --> pain alleviated
Spinal Stenosis
-Remember old folks bending over with their grocery cart --> pain alleviated
How is the Patrick's Test done?
Aka FABER test (Flexion, Abduction and External Rotation)
-Assess hip or sacroiliac joint
The Patrick's Test can be useful in assessing?
Pts with ankylosing spondylitis (sacroilitis)
Mr. Quinn, 40 y/o, Pacific Islander male who presents with a very painful swollen RT knee. He admits to injury while working at home. He hit himself with the hammer while nailing something. It did not break the skin & was painful initially & the pain gradually subsided. At about 3 a.m. he awoke in excruciating pain of the RT knee. It is assoc with throbbing, edema & erythema. Knee was so tender he could not tolerate his pajama pants or bedcovers touching it. Pain is unresponsive to 1000 mg of acetaminophen every 4 hrs. Pain is worse with walking & relieved upon elevation. Heat makes it worse & it's unresponsive to ice.
•PMHx -non contributory, NKDA
•Psychosocial: 6 beers per mnth but no wine or liquor. Yesterday after work he had about 10 beers with his buddies. •Family hx is unknown

Based on this info, which questions are essential to ask Mr. Quinn?
•What type of home improvement project was he performing?
•What is his sexual history?
•Has he been ill or experience a previous knee injury in the past month?
•Does he have fatigue, fever, malaise or rash?
•Are any other joints involved?
His home improvement project is installing cabinets. He is sexually active with women, is currently married & is in a monogamous relationship for the past 5 yrs. He has not been ill or has not sustained any previous knee injury. He felt febrile earlier in the day with mild fatigue but denies malaise. The only skin change is the redness in the knee. No other joints are affected.

Based on this info, which components of the PE are essential?
•Bilateral eye exam
•Bilateral knee & hip exam
•Lower ext pulse & vascular exam
•Lower ext reflex & sensation
PE findings:
•HT=61 in, WT=180 lbs, BMI= 25.1, BP=126/68, RR=14/Min, Regular, T=110.2 F •Knee: RT knee swollen, skin is reddish purple, (-) rashes on other extremities. On palpation knee is hot to touch & tender around patellar. ROM of RT knee is decreased. LT knee is without swelling, redness, tenderness or heat.
•Distal pulses equal bilaterally.
•Patellar reflex is 2+ on LT & poorly accessible on RT. Sensation intact on LT knee & RT knee is hypersensitive
•Based on this info which of the following dx studies are essential to perform:

•Arthrocentesis of RT knee w/ synovial fluid appearance
•Acid fast stain, Thayer martin & fungal culture
•Serum & synovial fluid for glucose, uric acid, protein & lactate levels
•Thayer martin blood cultures
•X-ray of knee
Arthrocentesis of RT knee w/ synovial fluid appearance
-Gram stain & cx to r/o infection
Lab Value Results for Synovial Fluid:

•Color: Straw colored and thin
•WBC: 2000/mm
•Gram stain (-)
•Polarized light: needle like crystals (-) birefringent
•Glucose = 86mg/dl
•Uric acid= 9.8mg/dl
•Protein =7.5 g/dl
•Lactate =130 U/L
Keep reading....
-Diff: Pseudogout crystals: short blunt rods, rhomboid & cuboids w/ weak (+) birefringement
Lab Value Results for Serum:

•Glucose= 95mg/dl
•Uric acid= 9.8mg/dl (NML 4-8.5)
•Protein= 7.4 g/dl
•Lactate= 130 U/L
Keep reading...
Based on this information. What is the most likely dx?

•Acute bacterial arthritis
•Acute gouty arthritis
•Psuedogout
•Rheumatoid arthritis
•Effusion secondary to trauma
Acute gouty arthritis
-Polarized light: needle like crystals (-) birefringent
-•Uric acid= 9.8mg/dl (NML 4-8.5)
(waiting for answers to be posted)
Based on the diagnosis, which of the following are appropriate components of a treatment plan for Mr. Quinn?

•Indomethacin 150 mg bid
•IV colchicine
•IV ABx
•Tapering dose of methylprednisone
•Allopurinol 100 mg bid
IV colchicine
-Colchine effective w/in 24 hrs of attack
-Allopurinol should not be started during an attack
(waiting for answers to be posted)
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