ROTATION HANDOUT FAMILY MEDICINE RESIDENTS ORTHOPEDICS ROTATION Gaetano P. Monteleone, Jr., M.D.

Dept of Family Medicine West Virginia University School of Medicine monteleoneg@wvuh.com PHYSICAL EXAM SKILLS Consider Magees Orthopedic Physical Assessment and Hoppenfelds Examination of the Spine and Extremities for further exam techniques in orthopedic medicine. I. ANKLE

Range of Motion (ROM) Dorsiflexion (0-20) Anterior tibialis, Toe extensors (hallucis longus, digitorum longus). Plantar flexion (0-50) Gastroc/soleus unit, Posterior tibialis, Toe flexors (hallucis longus and digitorum longus). Inversion (0-35) Anterior tibialis Eversion (0-15) Peroneus longus and brevis Special Tests 1. Anterior Drawer- measure translation (in mm)

ROTATION HANDOUT FAMILY MEDICINE RESIDENTS ORTHOPEDICS ROTATION Gaetano P. Monteleone, Jr., M.D. Dept of Family Medicine West Virginia University School of Medicine monteleoneg@wvuh.com 2. Talar Tilt- measure opening (in degrees)

3. Side-to-side (Cotton test)- especially for syndesmosis sprains

Side-to-side (Cotton) test- place examining hand under the plantar aspect of the foot/ankle, with your thumb under one malleolus and your middle finger under the other malleolus. Place a medial and lateral-directed force (not inversion/eversion stress as in the talar tilt test) on the ankle. Assess if translation and assess quality of endpoint. There may be a few mm of motion with a syndesmosis sprain. An alternative to this is to passively externally rotate the foot. Pain with this maneuver will occur in a syndesmosis sprain. 4. Proximal squeeze test- also for syndesmosis sprains

Proximal squeeze test- examiner squeezes mid-shaft of tibia/fibula. Pain in the syndesmosis area may indicate a syndesmosis sprain. 5. Neurovascular Compare to unaffected ankle!

II.

KNEE

Inspection- deformity, effusion, ecchymoses, erythema, Q angle, muscle asymmetry (atrophy). Palpation a. Anterior- patella, patellar tendon, quadriceps tendon, joint line, tibial tubercle. b. Medial- patellar retinaculum, MCL (origin and insertion), meniscus, pes anserine tendons, pes anserine bursa, medial femoral condyle, medial facet of the patella. c. Lateral- patellar retinaculum, LCL, lateral meniscus, iliotibial band (inserts at Gerdy's tubercle), lateral femoral condyle. d. Posterior- hamstring tendons, posterior joint line (posterior horns of the meniscus, popliteal fossa (neurovascular structures, Baker's cyst). e. Joint line tenderness- posterior joint line tenderness more sensitive for meniscal injury than anterior. Anterior joint line tenderness may reflect anterior knee pain syndromes, osteochondritis dessicans, etc. In addition, joint line tenderness is most sensitive if not associated with an ACL tear.

N.B. When palpating joint line, internal tibial rotation renders the lateral meniscus more palpable, external tibial rotation renders the medial meniscus more palpable. ROM/Flexibility- include hamstring flexibility. Decreased ROM (especially extension) may represent a tear that flips up and blocks full extension, AKA "locked knee."Tight hamstrings must be assessed. Special Tests for Patellofemoral problems a. Patellar apprehension test- patient supine: examiner provides lateral distraction to the patella; positive test is apprehension that the patella will dislocate. b. Patellar grind/compression tests- patient supine: active, isometric contraction of the quads by patient with posteriorly directed force placed on the patella by examiner. Positive test is
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reproduction of the patients pain with this maneuver. c. Q (quadriceps) angle- measure of genu valgus (knock-kneed). The angle created by two lines: one drawn from the middle of the patella and the tibial tubercle, and the other line from the middle of the patella and the ASIS of the iliac crest. Normal in males is < 10 , females < 15. Patients with high Q angles are at increased risk for patellofemoral conditions. d. "J" sign- patient in seated position: patient slowly extends knee to 0. Normally, examiner observes the patella gliding proximally with extension. A positive J sign is observed when as the knee approaches full extension, the patella will not only glide proximally, but will lateralize in the final degrees of extension (inverted "J"). Patients with malalignment or poor biomechanics will demonstrate a positive J sign. May indicate instability. Special Tests for Ligamentous abnormalities

Grading system for most ligament sprains/tears: Grade 1 2 3 Histology/Translation Fibers stretched, no laxity Few fibers torn, some laxity Many fibers torn, much laxity Endpoint Good Fair Poor, soft

a. Valgus/varus stress tests @ 0 and 30 of flexion: tests MCL/LCL, respectively. Instability during valgus stress with the knee in complete extension demonstrates both and MCL and ACL tears. b. Lachman's test for ACL. Knee in 30of flexion. Outside hand stabilizes the femur, inside hand around the tibia at the tibial tubercle. An anteriorly-directed force is applied. Assess for translation (in mm) and endpoint (good, fair, poor). This is the most accurate exam maneuver for ACL tears acutely. False negative tests occur when hamstring spasm with tense effusion, bucket-handle tears of meniscus. False positive test with PCL tear.

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c. Anterior/posterior drawer tests- for ACL and PCL, respectively. The knee is flexed to 90, hip at 45 with feet flat on exam table; examiner may sit on foot, apply an anteriorly or posteriorly-directed force. Maintain thumbs at joint line. Assess for translation and quality of endpoint. The a nterior drawer is generally not as helpful as the Lachman and pivot shift tests for ACL integrity. In addition, it requires more motion to an acutely injured knee. The posterior drawer test, on the other hand, is the most helpful test for PCL integrity. d. Pivot shift test- for ACL integrity. Start with knee straight and an examining hand under heel of foot. Turn the foot into internal rotation with one hand, place a valgus-directed force at the knee with the other hand. At the same time, bring the knee from extension to flexion. A palpable clunk appreciated at 30 of flexion at the joint line represents the tibia reducing on the femur in ACL-deficient knee. This may be quite uncomfortable for the acutely injured patient. It requires significant relaxation on the part of the patient, and they probably won't let you do it a second time (so get it right the first time!). This is the most accurate test for chronic tear of the ACL (> 6 months). e. Posterior sag sign- have patient lying relaxed and supine, with knees in position similar to the anterior/posterior drawer tests. In patients with a PCL tear, the tibial tubercle will sag posteriorly relative to the other tibial tuberosity. The quadriceps active test- for PCL integrity involves the same position. Active contraction of the quadriceps will shift the tibial tubercle anteriorly (back to neutral) in a patient with a PCL tear. Figure at right describes the posterior sag and the quadriceps active tests. f. Apley's distraction test- patient lying prone, knee
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flexed to 90, examiner stabilizes posterior femur in one hand and distracts the foot upward. At the same time, the foot should be rotated internally and externally. Reproduction of patients pain may indicate MCL/LCL sprain or tear. A variation to this is Apley's compression test. Performed similarly to the distraction test, the examiner produces a compression force from the heel directed into the exam table. Again, reproduction of pain with internal/external rotation of the foot is a positive test. This may indicate possible meniscal pathology. Note: in patients with open growth plates, positive Lachman's test, valgus/varus tests may actually represent opening of tibial or femoral growth plate fracture. Special tests for Meniscal tears a. McMurray test- positive test indicated by a palpable or audible clunk. Pain is not diagnostic. This test performed by palpating bilateral joint lines with the pt supine. The examiner produces internal/external tibial rotation while flexing and extending the knee. Simultaneously, the examiner produces a valgus or varusdirected force.

The value of this and other clinical exam tests for the meniscus has been questioned. The positive predictive value approximates 85%, for audible/palpable click. The positive predictive value is higher in the medial meniscus and lower for the lateral meniscus.

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b. Apley's compression test positive for pain. Pt prone. Knee flexed to 90. The examiner produces a compression force directed toward the exam table. Note distraction stress may stretch the collateral ligaments and create pain. This may distinguish MCL vs medial meniscus injury. III. HIP Physical Exam Inspection- deformity, ecchymoses, erythema, muscle asymmetry (atrophy). Palpation- Anteriorly palpate the ASIS, AIIS, pubic symphysis, neurovascular structures (femoral artery, vein and nerve), musculature; Laterally palpate the iliac crest, greater trochanteric bursa; posteriorly palpate the PSIS, gluteal muscles, greater sciatic notch, ischial tuberosity and bursa, SI joint, L-spine. Range of Motion (ROM)- flexion (0-120), extension (0-30), abduction (0-45), adduction (0-30), external rotation (0-50), internal rotation (0-40o) Special testsa. FABER test (Flexion, ABduction, External Rotation at the hip)- Pt places leg in figure of four position. Place the examining ankle on the contralateral knee and relax the knee out with external rotation of the hip. Tests for hip muscle flexibility, SI joint pathology. b. Trendelenberg sign- have pt stand on affected leg. Normal and negative test is an inclination of the contralateral PSIS. An abnormal (positive) test results in a drooping of the contralateral PSIS. May indicate gluteus medius weakness. c. Ortolanis and Barlows hip clunk for developmental dislocation of the hip (DDH). Ortolanis opening of the hips (abduction/external rotation) reduces a dislocated hip; Barlows closure of the hips (adduction/internal rotation) dislocates the hip again. These tests are best performed during the first few weeks of life. After that, false negative tests can occur due to muscular spasm, etc. d. Limb length discrepancy- measure ASIS to medial malleolus in cm. Compare both sides. Some discrepancy is normal. Correct for more than 1.0-1.5 cm. Most (90%) discrepancies due to soft tissue tightness, inflexibility rather than actual difference in bone length. e. Neurovascular assessment-. Femoral artery, nerve; nerve roots L1-S1. f. L-spine exam- a good hip exam includes an L-spine exam as well.

IV. BACK Physical Exam Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking Palpation- point tenderness (bony and soft tissue) Range of Motion- measure forward flexion in inches from the floor

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N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion are important. However, they have low diagnostic utility, since many causes of acute low back pain will manifest these signs. Neurovascular Assessment (most important is L4-S1): individually test heel and toe walking. Minor asymmetry is common. A positive test should show marked asymmetry. Nerve Root L4 L5 S1 Sensory Anterolateral thigh Medial ankle Posterolateral thigh Dorsum of ankle Lateral ankle Reflex Patellar ? Posterior tibialis Achilles Motor Tibialis anterior Extensor hallucis longus Peroneus

Cross innervation is common and may result in misinterpretation. For screening purposes, extensor hallucis longus (L5) is most important. Remember that differentiating a peripheral nerve abnormality is necessary. Posterior tibialis and gluteus medius muscles are innervated by L5 nerve root, but not the peripheral peroneal nerve. Note, these tests have only moderate sensitivity and specificity for nerve root irritation. Special Tests

a. Straight leg raise (SLR) + ankle dorsiflexion: pt supine, raise leg to 30-60; + test is pain that radiates into the calf. Also, crossed SLR = SLR in unaffected limb exacerbates radicular pain in affected limb. b. Modified SLR (? Lasegue's test): hip flexed to 90, knee flexed to 90, this should not cause pain if HNP; examiner then extends the knee until nerve root is stretched. Pain with knee extension may indicate nerve root irritation demonstrated with HNP or impingement with OA. c. Bowstring sign: SLR until pain, then flex the knee. This should reduce/extinguish pain if nerve root irritation.
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d. Seated straight leg raise: With pt seated, examiner passively extends the knee; + test produces radicular pain. e. FABER test = Flexion ABduction External Rotation of the hip: this position posterior may cause pain in SI joint pathology. f. One-leg extension (or Arabesque) test: pt stands on one leg with back in extension (examiner supports); + test of pain may indicate spondylolysis. g. Hamstring flexibility- pt supine, hip and knees both at 90 flexion; examiner attempts to passively straighten leg. h. Leg length evaluation- measure from ASIS to medial malleolus (in cm). V. SHOULDER

The physical exam will confirm or eliminate diagnostic possibilities suggested by the history. Each clinician should develop a systematic approach to their examination. The various components include the following. The various tests can be focused depending on the presenting history. Range of motion- abduction, forward flexion, internal and external rotation. Compare with unaffected side. Remember that in repetitive overhand athletes, external rotation is increased and internal rotation is slightly decreased in the throwing shoulder. Strength- test deltoid, supraspinatus, internal (subscap) and external (infraspinatus) rotators against manual resistance and compare with opposite side. While you are testing strength, also see if the specific maneuver causes pain which will indicate tendinitis. Once tendinitis is demonstrated, the key is to ask why- impingement and instability are two common causes of tendinitis. If indicated, manual muscle testing is carried out on other muscle groups including trapezius, rhomboids, serratus, latissimus, and pectoralis.

Ortho Rotation Handout Revised 11.4.04

Palpation- systematic palpation of bones and joints (SC joint, AC joint, clavicle, acromion, scapula, greater tuberosity of humerus). Palpation of muscles groups of the shoulder. Direct palpation of the insertion of the supraspinatus is best achieved by palpating the anterior shoulder with the humerus in slights extension. Special testsa. Cross chest (hyperadduction) test- for AC joint pathology. Affected hand to contralateral shoulder. Pain at AC joint diagnostic.

b.

Neer's sign (forward flexion/internal rotation) for subacromial impingement.

c.

Hawkin's sign (90 abduction and 45 of horizontal adduction, then humeral internal rotation) for sub- acromial impingement.

d.

e. f.

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Apprehension test (sitting position)- Pt is lying supine with humerus abducted to 90o and externally rotated to 90o. Apprehension test produces apprehension that shoulder will come out of joint. Tests for underlying instability. Yergason's test- resisted forearm supination testing biceps tendon pain. Speed's test (for biceps tendinitis)- performed with elbow extended, forearm supinated, and forward elevation of the humerus to approximately 60 with manual resistance. Pain recreated in bicipital groove constitutes 10

g.

h.

positive test for biceps tendon pain. Relocation test (Jobe)- with the patient in the same position as in d. The Jobe relocation test, position patient as in apprehension test, then grasp proximal humerus and apply anterior displacement followed by posterior displacement. Pain with anterior displacement followed by relief of pain with posterior displacement constitutes a positive test for anterior instability. Modified "Lachman's" of the shoulder- with patient in supine position, examiner places one hand behind proximal humerus while gently grasping the humerus at the bicondylar axis at the elbow. Patient's humerus is abducted approximately 120. With the elbow held steady the examiner gently translocates the humeral head anteriorly, evaluating for amount of excursion and quality of end point. Shoulder with anterior instability may show increase in laxity and difference in end point quality compared to unaffected side. Patient must be completely relaxed. Sulcus sign- with patient seated and arm held relaxed at side, examiner grasps lower humerus and applies an inferior force. Space or 'sulcus' may appear depending on amount of inferior instability. Compare with opposite arm.

i.

j.

Labral "clunk" test- same position as the test in 'h'. The examining hand behind the humeral head palpates for a "clunk" as the other hand moves the humerus in a rotary motion, in effect trying to trap the labral tear between the humeral head and glenoid. This is analogous to the McMurray's test for meniscal tears of the knee.

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Quick Guide to Neurologic Status to the Extremities UPPER EXTREMITY Root

C5 C6 C7 C8 T1

Reflex
Biceps Brachioradialis Triceps -------

Motor
Deltoid, Biceps Wrist Extension, Biceps Wrist Flexion, Triceps Interossei, Finger Flexion Interossei

Sensory
Lateral Arm Lateral Forearm, Thumb/index finger Middle finger Medial Forearm, Ring/pinky finger Medial Arm

Peripheral nerve
Radial nerve Ulnar nerve Median nerve Axillary nerve Musculocutaneous nerve

Motor
Wrist Extension Abduction pinky Thumb: pinch, opposition, and abduction Deltoid Biceps

Sensory
Dorsal thumb/index web space Distal ulnar pinky Distal radial index Lateral Arm Lateral Forearm

LOWER EXTREMITY Root

L4 L5 S1

Reflex
Patellar None-? Post Tibialis Achilles

Motor
Anterior Tibialis Ext Hallucis Longus Peroneus L & Br

Sensory
Medial Leg & Foot Lateral Leg, Dorsum Foot Lateral Foot

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Muscle Action and Innervation Upper Extremity Note: Range of motion= AAOS; innerv= Hoppenfeld's I. Shoulder A. Abduction (0-180) 1 supraspinatus (C5-6) suprascapular n. mid deltoid (C5-6) axillary n. 2 ant & post deltoid serratus anterior B. Adduction pectoralis major (C5-T1) med & lat anterior thoracic n. latissimus dorsi (C6-8) thoracodorsal n. teres major ant deltoid C. Flexion (0-180) ant deltoid (C5) axillary n. coracobrachialis (C5-6) musculocutaneous n. pectoralis major (clavicular head) biceps ant deltoid D. Extension (0-60) latissimus dorsi (C6-8) thoracodorsal n. teres major (C5-6) lower subscapular n. post deltoid (C5-6) axillary n. teres minor triceps (long head) E. Internal (medial) rotation (0-70) subscapularis (C5-6) upper & lower subscapular nn. pectoralis major (C5-T1) med & lat anterior thoracic n. latissimus dorsi (C6-8) thoracodorsal n. teres major (C5-6) lower subscapular n. ant deltoid F. External (lateral) rotation (0-90) infraspinatus (C5-6) suprascapular n. teres minor (C5) br of axillary n. post deltoid

1 2

1 2

1 2

G. Scapular elevation
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1 2 1

trapezius CN XI levator scapulae (C3-4) rhomboids H. Scapular Protraction serratus anterior (C5-7) long thoracic n. I. Scapular Retraction rhomboids (C5) dorsal scapular n. Elbow A. Flexion (0-150) biceps (C5-6) musculocutaneous n. brachialis (C5-6) musculocutaneous n. brachioradialis supinator B. Extension triceps (C7) radial n. anconeus C. Supination biceps (C5-6) musculocutaneous n. supinator (C6) radial n. D. Pronation pronator teres (C6) median n. pronator quadratus (C8-T1) anterior interosseous n. Wrist A. Flexion (0-80) flexor carpi radialis, FCR (C7) median n. flexor carpi ulnaris, FCU (C8) ulnar n. B. Extension (0-70) extensor carpi radialis longus, ECRL (C6) radial n. extensor carpi radialis brevis, ECRB (C6) radial n. extensor carpi ulnaris, ECU (C7) radial n.

1 II. 1 2

1 2

III. 1

Lower Extremity
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I. 1 2

Hip A. Abduction (0-45) gluteus medius (L5) superior gluteal n. gluteus minimus B. Adduction (0-30) adductor longus (L2-4) obturator n. adductor brevis & magnus C. Flexion (0-120) Iliopsoas (L1-3) femoral n. Rectus femoris D. Extension (0-30) gluteus maximus (S1) inferior gluteal n. hamstrings E. External Rotation (0-50) gluteus maximus (L5-S 2) inferior gluteal n. obturator m (L3-S1) obturator n. piriformis F. Internal Rotation adductors (L2-4) obturator n. gluteus medius and minimus Knee A. Flexion (0-135) semimembranosus (L5) tibial n. semitendinosus (L5) tibial n. } Hamstrings biceps femoris (S1) tibial n. B. Extension quadriceps (L2-4) femoral n. Ankle A. Dorsiflexion (0-20) tibialis anterior (L4) deep peroneal n. extensor hallucis longus (L5) deep peroneal n. extensor digitorum longus (L5) deep peroneal n. B. Plantar flexion (0-50) gastroc/soleus (S1-2) tibial n. peroneus longus & brevis (S1) superficial peroneal n. flexor hallucis longus flexor digitorum longus } (L5) tibial n. 15

1 2 1 2

1 2

1 2

1 2 II. 1

1 III. 1

1 2

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 tibialis posterior C. Inversion (0-35) tibialis anterior (L4) deep peroneal n. D. Eversion (0-15) peroneus longus & brevis (S1) superficial peroneal n.

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Common Xrays Ordered in the Sports Medicine Clinics Ankle AP Lateral Mortise (20 internal rotation) AP Lateral Obliques X 2 ? Trauma Open mouth (Fuchs) view Lateral flexion/extension views (must be done at NCBH) AP Lateral Optional = radial head view, obliques X 2 AP Lateral Oblique PA Lateral Oblique PA Lateral Optional = oblique AP pelvis Lateral of L-spine Frog leg lateral AP Weightbearing (if ? DJD) Lateral Merchant (or other tangential view: ie- sunrise) Tunnel /notch (? OCD)

C-spine

Elbow

Foot

Forearm

Hand

Hip

Knee

Leg

AP tibia/fibula Lateral tibia/fibula Optional = oblique tibia/fibula AP Lateral Obliques X 2

L-spine

Shoulder

Trauma

Standing AP and lateral if ? listhesis AP with IR/ER Axillary lateral (West Point) view Scapulolateral "Y" view

Impingement AP with IR/ER Axillary lateral Supraspinatus outlet (Alexander) view Instability AC joint Wrist include True AP AP with caudal tilt (15) PA Lateral Oblique Optional = scaphoid view (AP with ulnar deviation) and carpal tunnel view

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