SHOULDER

QUESTION 1. AGE

ANSWER

CLINICAL APPLICATION Rotator cuff tear/impingement, arthritis (OA), adhesive capsulitis (frozen shoulder), humerus fracture (after trauma) Instability, AC injury, osteolysis, impingement in athletes Fracture, rotator cuff tear, acromioclavicular injury, dislocation Impingement, arthritis AC joint arthrosis Classic for Rotator Cuff tear, tumor Rotator Cuff tear Cervical radiculopathy

OLD YOUNG

2.

PAIN a. b. c. d.

Acute Onset Location Occurrence Exacerbating /relieving Chronic On top/AC joint Night pain Overhead worse Overhead better

3. 4.

STIFFNESS INSTABILITY

Yes Slips in and out Direct blow

Osteoarthritis, adhesive capsulitis Dislocation: >90% anterior - occurs with abduction & external rotation (e.g. throwing motion) Acromioclavicular injury Glenohumeral dislocation

5.

TRAUMA

Fall on outstretched hand Overhead usage Weight lifting Athlete: throwing type Long term manual labor

Osteolysis (distal clavicle) Rotator cuff tear/impingement Arthritis (OA)

6.

WORK/ACTIVITY

7. 8.

Neurologic Symptoms PMHx

Numbness/tingling/ heavy Cardiopulmonary/GI

Thoracic outlet syndrome, brachial plexus injury Referred pain to shoulder

PHYSICAL EXAM EXAM TECHNIQUE/FINDINGS

CLINICAL APPLICATION

EXAM Symmetry Wasting Gross deformity Gross deformity Gross deformity

TECHNIQUE/FINDINGS INSPECTION Compare both sides Loss of contour/muscle mass Superior displacement Anterior displacement "Popeye" arm PALPATION

CLINICAL APPLICATION

Rotator Cuff tear Acromioclavicular injury (separation) Anterior dislocation (glenohumeral joint) Biceps tendon rupture (usually proximal end of long head) Pain indicates Acromioclavicular pathology Pain: bursitis and/or supraspinatus tendon rupture Pain indicates impingement Pain indicates Rotator Cuff tendinitis Pain indicates biceps tendinitis 0-160 normal 0-160/180 normal Mid thoracic normal-compare sides 30-60 normal

AC joint Subacromial bursa Coracoclavicular ligament Greater tuberosity Biceps tendon Forward flexion Abduction Internal rotation

Feel for end of clavicle Feel acromion-down to acromiohumeral sulcus Feel between acromion & coracoid Prominence on lateral humeral head Feel proximal insertion on humerus RANGE OF MOTION Arms from sides forward Arms from sides outward Reach thumb up back-note level

External rotation

1. 2.

Elbow at side, rotate forearms lateral Abduct arm to 90, externally rotate up

External rotation decreased in adhesive capsulitis

UPPER ARM

QUESTION 1. AGE

ANSWER Young Middle age, elderly

CLINICAL APPLICATION Dislocation, fracture Tennis elbow (epicondylitis), arthritis

2. PAIN a. Onset Acute Dislocation, fracture, tendon avulsion/rupture, ligament injury

QUESTION

ANSWER Chronic Anterior Posterior Lateral Medial

CLINICAL APPLICATION Cervical spine pathology Biceps tendon rupture, arthritis Olecranon bursitis Lateral epicondylitis, fracture (especially radial head-hard to see on x-ray) Medial epicondylitis, nerve entrapment, fracture, MCL strain Infection, tumor Ligamentous and/or tendinous etiology Arthritis, effusions (trauma) Loose body, Lateral collateral ligament injury Olecranon bursitis. Other: dislocation, fracture, gout

b.

Location

c.

Occurrence

Night pain/at rest With activity Without locking With locking

3. STIFFNESS

4. SWELLING 5. TRAUMA 6. ACTIVITY

Over olecranon

Fall on elbow, Dislocation, fracture hand Sports, repetitive motion Pain, numbness, tingling Epicondylitis, ulnar nerve palsy

7. NEUROLOGIC SYMPTOMS

Nerve entrapments (multiple possible sites), cervical spine pathology, thoracic outlet syndrome

8. HISTORY OF ARTHRITIDES

Multiple joints Lupus, rheumatoid arthritis, psoriasis involved

PEMERIKSAAN FISIK

EXAM/OBSERVATION Gross deformity, swelling Carrying angle (normal 515)

TECHNIQUE Compare both sides Negative (< 5 degrees) Positive (> 15 degrees)

CLINICAL APPLICATION INSPECTION Dislocation, fracture, bursitis Cubitus varus: physeal damage (e.g. malunion supracondylar fracture) Cubitus valgus: physeal damage (e.g. lateral epicondyle fracture) Pain: medial epicondylitis (Golfer's elbow), fracture, MCL rupture

PALPATION Medial Epicondyle & supracondylar line

Ulnar nerve in ulnar groove Lateral Epicondyle & supracondylar line Radial head Anterior Posterior Biceps tendon in antecubital fossa Flex elbow: olecranon & olecranon fossa TECHNIQUE

Parathesias indicate ulnar nerve entrapment Pain: lateral epicondylitis (Tennis elbow), fracture Pain: arthritis, fracture, synovitis Pain can indicate biceps tendon rupture Olecranon bursitis, triceps tendon rupture

EXAM/OBSERVATION Flex and extend Pronate and supinate

CLINICAL APPLICATION Normal: 0-5 to 140-150; note if PROM > AROM Normal: supinate 90 degrees, pronate 80-90 degrees

RANGE OF MOTION Elbow at side, flex & extend at elbow Tuck elbows, pencils in fists, rotate wrist

FORE ARM

QUESTION

ANSWER Young

CLINICAL APPLICATION Trauma: fractures and dislocations, ganglions Arthritis, nerve entrapments, overuse Trauma Arthritis Kienbock's disease, ganglion Carpal tunnel syndrome (CTS), ganglion (especially radiovolar) Scaphoid fracture, DeQuervain's tenosynovitis, arthritis Triangular Fibrocartilage Complex(TFCC) tear, tendinitis

1. AGE

Middle ageelderly

Acute 2. PAIN a. b. Chronic Onset Location Dorsal Volar Radial Ulnar

3. STIFFNESS

with dorsal pain with volar pain (at night)

Kienbock's disease Carpal tunnel syndrome

QUESTION

ANSWER Joint: after trauma

CLINICAL APPLICATION Fracture or sprain Arthritides, infection, gout Flexor or extensor tendinitis (calcific), DeQuervain's disease Scapholunate dissociation Ganglion Fractures: distal radius, scaphoid; Dislocation: lunate, ulna TFCC tear Carpal Tunnel Syndrome (CTS), DeQuervain's tenosynovitis Nerve entrapment, thoracic outlet syndrome, radiculopathy Nerve entrapment (median (e.g. CTS), ulnar, or radial) Arthritides

4. SWELLING

Joint: no trauma Along tendons

5. INSTABILITY 6. MASS 7. TRAUMA

Popping, snapping Along wrist joint Fall on hand Repetitive motion (typing) Numbness, tingling Weakness Multiple joints involved

8. ACTIVITY

9. NEUROLOGIC SYMPTOMS

10. HISTORY OF ARTHRITIDES

PEMERIKSAAN FISIK

EXAMINATION

TECHNIQUE INSPECTION Bones and soft tissues Especially dorsal or radial Diffuse Warm, red Cool, dry Palpate each separately Both proximal and distal row Proximal row Pisiform

CLINICAL APPLICATION Fractures, dislocations: forearm and wrist Ganglion Trauma, infection Infection, gout Neurovascular compromise Tenderness may indicate fracture Snuffbox tenderness: scaphoid fracture; lunate tenderness: Kienbock's disease. Scapholunate dissociation Tenderness: pisotrequetral arthritis or FCU tendinitis

Gross deformity Swelling

PALPATION Skin changes Radial and Ulnar styloids Carpal bones

Soft tissues

6 dorsal extensor Tenderness over 1st compartment: DeQuervain's disease compartments Tenderness indicates TFCC injury TFCC: distal to ulnar styloid Firm/tense compartments: compartment syndrome Compartments

EXAMINATION

TECHNIQUE Flex (toward palm), extend opposite

CLINICAL APPLICATION

RANGE OF MOTION Flex and extend Radial/ulnar deviation Pronate and supinate Normal: flexion 80, extension 75

In same plane as the palm Normal: radial 15-20, ulnar 30-40 Flex elbow 90: hold pencil, Normal: supinate 90, pronate 80-90 (only 10-15 is in rotate wrist the wrist, most motion is in elbow)

HAND

QUESTION 1. HAND DOMINANCE 2. AGE 3. PAIN a. Onset b. Location 4. STIFFNESS 5. SWELLING Acute Chronic Young

ANSWER Right or left Middle age, elderly

CLINICAL APPLICATION Dominant hand injured more often Trauma, infection Arthritis, nerve entrapments Trauma, infection Arthritis Arthritis (OA) especially in women Purulent tenosynovitis (1 Kanavel signs) Trigger finger, rheumatoid arthritis Infection (e.g. purulent tenosynovitis, felon, paronychia) Arthritides, gout, tendinitis Ganglion, Dupuytren's contracture, giant cell tumor Fracture, tendon avulsion Infection

CMC (thumb) Volar (fingers) In AM, with catching After trauma No trauma

6. MASS 7. TRAUMA Fall, sports injury in dirty environment Sports, mechanic Pain, numbness, tingling Weakness 10. HISTORY OF ARTHRITIDES Multiple joints involved

8. ACTIVITY 9. NEUROLOGIC SYMPTOMS

Trauma (e.g. fracture, dislocation, tendon rupture) Nerve entrapment (e.g. carpal tunnel), thoracic outlet syndrome, radiculopathy Nerve entrapment (usually in wrist or more proximal) Rheumatoid arthritis, Reiter syndrome, etc

PEMERIKSAAN

EXAMINATION

TECHNIQUE

CLINICAL APPLICATION

EXAMINATION Gross deformity

TECHNIQUE INSPECTION Ulnar drift or swan neck Rotational or angular deformity

CLINICAL APPLICATION Rheumatoid arthritis Fracture Dupuytren contracture, purulent tenosynovitis Neurovascular disorders: Raynaud's, diabetes, nerve injury Nodes from osteoarthritis: Heberden's (at DIPs: #1), Bouchard's (at PIPs) Rheumatoid arthritis Purulent tenosynovitis Median nerve injury, CTS, C8/T1 pathology, CMC arthritis Ulnar nerve injury CLINICAL APPLICATION PALPATION Infection Neurovascular compromise Tenderness may indicate fracture Tenderness: fracture, arthritis; Swelling: arthritis Wasting indicates median & ulnar nerve injury respectively Nodules: Dupuytren's contracture; Snapping with finger extension: Trigger finger

Finger position Skin, hair, nail changes Swelling

Flexion Cool, hairless, spoon nails, etc. DIPs PIPs MCP's Fusiform shape finger

Muscle wasting

Thenar eminence Hypothenar eminence or intrinsics

EXAMINATION Skin Metacarpals Phalanges & finger joints Soft tissues

TECHNIQUE Warm, red Cool, dry Each along its length Each separately Thenar & hypothenar eminences Palm (palmar fascia)

Flexor tendons: along volar Tenderness suggests purulent tenosynovitis finger Sides of finger All aspects of finger tip Finger: MCP joint PIP joint DIP joint Thumb: CMC joint Flex 90, extend 0, Add/abd 0-20 Flex 110, extend 0 Flex 80, extend 10 Giant cell tumors Tenderness: paronychia or felon Decreased flexion if casted in extension (collateral ligaments shorten) Hyperextension leads to swan-neck deformity All fingers should point to scaphoid at full flexion RANGE OF MOTION

Radial abduction: Flex 50, Motion is in plane of palm extend 50

EXAMINATION

TECHNIQUE Palmar abduction: Abduct 70, adduct 0

CLINICAL APPLICATION Motion is perpendicular to plane of the palm

MCP joint IP joint Opposition

In plane of palm: Flex 50, extend 0 In plane of palm: Flex 90, extend 10 Touch thumb to small fingertip Motion is mostly at CMC joint

THIGH / HIP

QUESTION 1. AGE

ANSWER Young Middle age, elderly

CLINICAL APPLICATION Trauma, developmental disorders Arthritis (inflammatory conditions), femoral neck fractures Trauma, infection Arthritis (inflammatory conditions) Bursitis, LFCN entrapment, snapping hip Consider spine etiology Hip joint or acetabular etiology (less likely to be from pelvis or spine) Proximal femur Hip joint etiology (i.e. not pelvis or spine) Tumor, infection Snapping hip syndrome, loose bodies, arthritis, synovitis Use (and frequency) indicates severity of pain & condition Less distance walked and fewer activities no longer performed = more severe Fracture, dislocation, bursitis Femoral stress fracture LFCN entrapment, spine etiology Systemic inflammatory disease

2. PAIN a. Onset b. Location c. Occurrence

Acute Chronic Lateral hip or thigh Buttocks/posterior thigh Groin/medial thigh Anterior thigh Ambulation/motion At night With ambulation Cane, crutch, walker Walk distance & activity cessation Fall, MVA Repetitive use Pain, numbness, tingling Multiple joints involved

3. SNAPPING 4. ASSISTED AMBULATION 5. ACTIVITY TOLERANCE 6. TRAUMA 7. ACTIVITY/WORK 8. NEUROLOGIC SYMPTOMS 9. HISTORY OF ARTHRITIDES

PEMERIKSAAN FISIK

EXAM/OBSERVATION TECHNIQUE

CLINICAL APPLICATION

INSPECTION

EXAM/OBSERVATION TECHNIQUE Skin Gait Antalgic (painful) Lurch (Trendelenburg) Lurch Steppage Flat foot Wide Decreased step size Discoloration, wounds Gross deformity 60%stance, 40%swing

CLINICAL APPLICATION Trauma Fracture, dislocation Normal gait: 20% double stance (both feet on ground)

Decreased stance phase Knee, ankle, heel (spur), midfoot, toe pain Laterally (on WB side) Gluteus medius weakness, hip disease (OA, AVN) Posteriorly (hip extended) More hip & knee flexion No push off Feet > 4 inches apart Less than previous normal Greater trochanter/bursa Sciatic nerve (hip flexed) Muscle groups Gluteus maximus weakness Foot drop, weak anterior leg muscles Hallux rigidus, gastrocnemius/soleus weakness Neurologic/cerebellar disease Pain, age, other pathology

PALPATION Bony structures Soft tissues Pain/palpable bursa: infection/bursitis, gluteus medius tendinitis Pain: disc herniation, piriformis spasm Each group should be symmetric bilaterally CLINICAL APPLICATION RANGE OF MOTION Flexion Supine: knee to chest Thomas test: see next page Extension Abduction/adduction Internal / External rotation Prone: lift leg off table Supine: leg lateral/medial Seated: foot lateral/medial Normal: 130 degrees Rule out flexion contracture Normal: 20 degrees Normal: Abd: 40 degrees, Add: 30 degrees Normal: IR: 30 degrees, ER: 50 degrees

EXAM/OBSERVATION TECHNIQUE

Prone: flex knee leg: in Normal: IR: 30 degrees, ER: 50 degrees & out

LEG AND KNEE

QUESTION 1. AGE

ANSWER Young

CLINICAL APPLICATION Trauma: fractures, ligamentous or meniscal injury

QUESTION 2. PAIN a. Onset

ANSWER Middle age, elderly Acute Chronic

CLINICAL APPLICATION Arthritis Trauma: fracture, dislocation, soft tissue (ligament/meniscus) injury, septic bursitis Arthritis, infection, tendinitis/bursitis, tumor Quadricep or patellar tear or tendinitis, prepatellar bursitis, patellofemoral arthritis Meniscus tear (posterior horn), Baker's cyst, popliteal aneurysm Meniscus tear (jointline), collateral ligament injury, arthritis, ITB friction syndrome Meniscus tear (jointline), collateral ligament injury, arthritis, pes bursitis Tumor, infection Etiology of pain likely from joint Arthritis, effusion (trauma, infection) Loose body, meniscal tear (especially bucket handle), arthritis, synovial plica Infection, trauma Acute (hours): ACL injury; Subacute (day): meniscus injury Cruciate ligament injury, extensor mechanism injury Patellar subluxation/dislocation, pathologic plica, osteochondritis dissecans MCL injury (+/- terrible triad: MCL, ACL, medial meniscus injuries) LCL injury Non-contact: ACL injury, Contact: multiple ligaments Cruciate ligament injury (especially ACL), osteochondral fracture Degenerative and overuse etiology Cruciate and/or collateral ligament injury Patellofemoral etiology Mensicus tear Distance able to ambulate equates with severity of arthritic

b. Location

Anterior Posterior Lateral Medial

c. Occurrence 3. STIFFNESS

Night pain With activity Without locking With locking or catching

4. SWELLING

Within joint Acute (post injury)

Acute (without injury) Infection: prepatellar bursitis, septic joint 5. INSTABILITY Giving away/collapse Giving away,+/- pain 6. TRAUMA Mechanism: valgus force Varus force Contact injury Popping noise NONE 7. ACTIVITY Agility sports Running, cycling, climbing Squatting Walking

Flexion/posterior force PCL injury (e.g. dashboard injury)

QUESTION 8. NEUROLOGIC SYMPTOMS 9. SYSTEMIC COMPLAINTS 10. HISTORY OF ARTHRITIDES

ANSWER Pain, numbness, tingling Fevers, chills Multiple joints involved

CLINICAL APPLICATION disease Neurologic disease, trauma Infection, septic joint Rheumatoid Arthritis, gout, etc.

PEMERIKSAAN FISIK

EXAM Gait Anterior

TECHNIQUE/FINDINGS CLINICAL APPLICATION INSPECION Observe patella tracking Flexed knee gait Abnormal patella tracking can lead to patellofemoral problems Tight Achilles tendon or hamstrings: patellofemoral problems

Genu valgum (knock knee) Normal: 7 degrees valgus; varus or valgus deformity with Genu varum (bow leg) ligamentous or osseous deficiency Swelling Effusion (arthritis, trauma, infection/inflammation), bursitis (prepatellar, infrapatellar) Effusion (arthritis), Baker's cyst

Posterior Lateral

Swelling, mass

Back knee, high/low riding Genu recurvatum (PCL injury), patella alta (patellar instability) patella Vastus medialis atrophy: can lead to patellofemoral problems PALPATION Tenderness at distal pole: tendinitis (Jumpers knee) Tenderness with Osgood Schlatter disease Ballotable patella (effusion): arthritis, trauma, infection Edematous or tender bursae indicate correlating bursitis Tenderness indicates bursitis Thickened, tender plica is pathologic Tenderness: medial meniscus tear or MCL injury Tenderness: lateral meniscus tear or LCL injury Pain or tightness is pathologic

Musculature Atrophy Bony structures Patella: medial & lateral aspects Tibial tubercle Soft tissues Compress suprapatellar pouch (milk knee) Prepatellar/infrapatellar bursae Pes anserine bursa Plica (medial to patella) Medial jointline & MCL Lateral jointline & LCL Iliotibial band (anterolateral knee) Popliteal fossa

Mass consistent with Baker's cyst, popliteal aneurysm

EXAM

TECHNIQUE/FINDINGS CLINICAL APPLICATION Compartments of leg Firm or tense compartment: Compartment syndrome (anterior, posterior, lateral)

EXAM Flexion & extension

TECHNIQUE/FINDINGS CLINICAL APPLICATION RANGE OF MOTION Supine: knee to chest, then Normal: Flex 0 to 125-135, Extend 0 to 5-15; straight Extensor lag (final 20 difficult): weak quadriceps; Decreased extension with effusion Note patellar tracking, pain, & crepitus Abnormal tracking leads to anterior knee pain; pain & crepitus: arthritis

Tibial IR & Stabilize femur, rotate tibia Normal: 10-15 IR & ER ER