Provocative Testing &
Diagnostics of Upper & Lower
Extremity Conditions
Tom Winters, MD, FACOEM, FACPM
Chief Medical Officer
CareGroup Occupational Health Network
Walter Panis, MD
Medical Director
CareGroup Occupational Health Network
June 6, 2002
Copyright 2002 CareGroup
Occupational Health Network
The Knee
• Approx. 10.8 million knee
injuries per year in general
population
• Why so many injuries
– Largest joint in body
– Dynamic nature of joint
increases vulnerability
– Very little bony stabilityrelies on normal ligaments,
cartilage and tendons
Ref: AAOS Research Dept., Pt. Visits for selected conditions, 1998
Anatomy of the Knee
• Bones:
– Femur
– Tibia
– Patella
• Cartilage (shock
absorbers)
– Lateral Meniscus
– Medial Meniscus
– Articular cartilage is
nerveless
Anatomy of the Knee
• Ligaments
– 4 major ligaments
(attach bone to bone)
•
•
•
•
Anterior Cruciate
Posterior Cruciate
Medial Collateral
Lateral Collateral
Anatomy of the Knee
• Patellar and Extensor
tendons (attach
Quadriceps to bone)
– Major tendons
• Synovium
– Inner joint lining
• Synovial fluid
– Joint lubrication
Types of Knee Injuries
• ACL tear
• Bursitis (“Housemaids
knee”)
• Collateral ligament
tear
• Posterior ligament
tear
• Meniscal tear
•
•
•
•
Fracture of tibia
Fracture of patella
Sprain/strain
Patellar/quadriceps
tendinitis
• Patellofemoral pain
• Extensor mechanism
rupture
Types of Knee Injuries
• Ligament Injuries
– ACL: changing direction
quickly, twisting, pivoting,
deceleration activities
– PCL: blow to front of knee
(“dashboard injury”),
hyperextension /
hyperflexion
– MCL: contact with outside
of knee, valgus force
(common)
– LCL: knee forced laterally,
varus force (less common)
Types of Knee Injuries (cont.)
• Meniscal Tears
– Medial/Lateral
Meniscal Tear:
• Twisting,cutting,
pivoting, rapid
deceleration types of
motions
• Movement around a
fixed lower leg
(stationary) or planted
foot
Examination of the Knee
• Inspection (always examine
uninjured knee 1st!)
–
–
–
–
–
Note onset- acute/gradual
Type/quality of pain
Posture
Bony deformities
Muscle wasting
• Quad wasting esp. in VM O
seen with knee injury
– Soft tissue swelling
• Effusion of suprapatellar
pouch, pre and infrapatellar
bursae, palpable joint line
swelling
– Masses/lumps
– Old scars
– Pulses
Examination of the Knee (cont.)
• Palpation
– Check bilaterally for temperature
differences, inflammation
– Palpate medial and lateral
collateral compartments
– Bursae
– Medial/lateral meniscus
– Medial/lateral ligament
• Medial more common
• “Bucket-handle” tear
– Popliteal fossa
Examination of the Knee (cont.)
• Palpation (cont.)
– Bony landmarks
• Medial and lateral joint
lines
• Patello-femoral joint
• Tibial tuberosity
• Femoral condyles
– Reflexes
– Always check joint above
and below (hip and ankle);
hip pain may be referred to
knee!
Examination of the Knee (cont.)
• Range of motion
– Flexion = 130+
degrees
– Extension = 0 (-10) degrees
Special Knee Tests
• Tests for ACL laxity
– Anterior drawer sign
– Lachman’s test
– Pivot shift
Anterior Draw Test
Lachman’s Test
Ref: Snider, R. The Essentials of Musculoskeletal Care.
AAOS: 1997
Special Knee Tests (cont.)
Posterior sag sign
• PCL stress tests
–
–
–
–
http://www.wokc2.com/topic3.htm
Posterior sag sign
Reverse Lachman’s
Posterior draw sign
Reverse pivot test
Special Knee Tests (cont.)
• McMurray’s/ Apley’s grind
test (meniscus)
• Apprehension test (patella)
• Crepitus sub-patella
• Pathological “locking/giving
out”
McMurray’s Test
– Due to intra-articular fragment
of bone or cartilage wedging
between femoral & tibial
condyles
– Joint unable to fully extend
(fixed flexion deformity)
Ref: Hoppenfeld,S. Physical Examination of the Spine & Extremities. Prentice-Hall: 1976.
Grading Ligament Injuries
• Grade I (sprain):
– Micro-tearing or stretching
– Joint is stable
• Grade II (sprain):
–
–
–
–
Partial disruption of ligament
Painful to stress joint
Joint laxity with endpoint
Mild effusion
• Grade III (tear):
– Complete tear
– Joint laxity without endpoint
–   effusion
Diagnostic Procedures
• X-ray
– Indications
• MRI
– Best to view:
• Meniscus, ligaments, soft
tissue
– Indications
• CAT Scan
– Best to view:
• Bone
– Indications
Diagnostic Procedures
• Arthrogram
(infrequently performed)
• Arthroscopy
(preferred method)
Treatment of Knee Injuries
•
•
•
•
•
Rest
Ice
Compression
Elevation
Anti-inflammatories
– NSAIDs
– COX-2
Types of Knee Braces
• Types of bracing:
– Prophylactic
– Functional
– Rehabilitative/knee
immobilizer
– Patellorfemoral
• Often work better in lab
than in real life use
• Functional and
Rehabilitative seem to be
of most use
• Stretching,
strengthening,and
technique improvement
more important in long
Anatomy of the Foot and Ankle
• Bones
– “True ankle joint”
• Tibia
• Fibula
• Talus
A.
Second part of ankle
• Subtalar joint
• Calcaneus (heal)
– Foot
• Tarsals
• Metatarsals
• Phalanges
Ref: http://www.soarmedical.com/medical-library/foot&ankle/
Anatomy of the Foot and Ankle
(cont.)
• Cartilage & ligaments
– Articular cartilage (1)
– Anterior tibiofibular (2)
• Connects tibia to fibula
• Most commonly injured
– Collateral lateral ligaments (3)
• Attaches fibula to calcaneuslateral stability
– Deltoid ligaments (4)
• Connect tibia to talus and
calcaneus- medial stability
Ref: http://www.scoi.com/anklanat.htm
Anatomy of the Foot and Ankle
(cont.)
• Tendons
– Achilles tendon
– Anterior tibial tendon
– Posterior tibial tendon
Examination of the Ankle and
Foot
• Inspection
– Ecchymosis, bony abnormalities, soft tissue swelling,
effusion
– Note type of footwear- note wear pattern on soles
– Gait
• Palpation
– Tenderness- certain areas of foot normally tender
i.e.sinus tarsi, distal aspect of ball between metatarsals
– Neurovascular status- Pulses, sensation
– Crepitation
– Tinel’s sign (+ peroneal nerve injury)
• Range of motion
Special Tests of the Ankle and
Foot
•
•
•
•
•
•
Eversion stress (Medial stress test)
Drawer test
Anterior drawer test (tests stability-ATF ligament)
Lateral stress
External rotation test (Kleiger test)
Squeeze test (testing for fx of
tibia or fibula)
• Heel tap test
Types of Ankle and Foot Injuries
• Plantar fasciitis
• Tarsal tunnel
syndrome (ladders)
• Insertional Achilles
tendinitis
• Stress fracture of
calcaneus
• March fracture (stress
fx)
• Sesamoiditis
• Fracture of the
sesamoid
Sprain versus Strain
• Sprain: twisting of joint
that stretches or tears
ligaments, no dislocation
of bones, may damage
nearby blood vessels,
muscles, tendons, swelling
and hemorrhage
• Strain: less serious injury,
overstretched tendon or
partially torn muscle
Types of Ankle Injuries:
Sprains
• 1st degree: no (mild) edema, point
tenderness, ligament stretching,
no rupture (maybe crutches/cane)
• 2nd degree: partial ligament
rupture, edema, point
tenderness, difficulty/inability to
weight bear on ankle
(crutches,splint)
• 3rd degree: complete disruption
one or more ligaments/other
structures,   edema,
ecchymosis, general tenderness,
inability to bear weight
(crutches,splint, cast, surgery)
Ankle Sprains
• Forced inversion strain
– Stretch, tear or rupture
of lateral collateral
ligament complex
(possibly anterior talofibular lig.)
• Forced eversion strain
– Stretch, tear or rupture
of medial collateral
ligament
• Lateral ankle
compartment more
commonly injured than
medial
Foot and Ankle Fractures
• Types
– Jones (fx of proximal metaphysis
of 5th metatarsal)
• Diagnosis
– Routine use of x-rays to rule out
sprain vs. fx “to do or not to do”clinical indications
– Ottawa rules for foot and ankle
radiographs (see web site)
http://www.aafp.
org/afp/980201ap/wexler.html
• Treatment
– ORIF
– Casting
Foot and Ankle Fractures
Traumatic Injury
• Direct trauma = external
force strikes the foot
• Indirect trauma = force
transmitted to stationary
foot so that weight of
body becomes a
deforming force by torque,
rotation or, compression
Ref: http://www.aafp.org/afp/980700ap/burrough.html
Pain
• Why are ankle injuries
so painful?
– Rich nerve supply
(pain and
proprioception is
enhanced)
– All ligaments have
poor blood supply:
slow to heal, heals with
scar tissue, retains
stretched condition
Non-Surgical Treatment of Ankle
Injuries
•
•
•
•
Rest
Ice
Compression
Elevation
Types of Ankle Support
• Non-rigid (1st degree sprains):
– Elastic wrap/neoprene
• Not OSHA recordable
• Purpose: compression, nonsupportive
• Rigid: (1st, 2nd, 3rd degree
sprains)
– Lace-up, Aircast
• Purpose: support, proprioception
– Bracing
•
•
•
•
AFO (ankle foot orthosis)
Walking boot
Cast shoe
Cast
Physical Therapy for Knee and
Ankle Injuries
• Does every lower
extremity injury require
physical therapy?
– Benefits
– How soon after injury
should it be ordered?
• Home exercises versus
clinic therapy program
– Nature of injury
– Patient compliance issues
Goals of Rehabilitation
• Restoration of comfort
– Decrease edema
• R.I.C.E.
– Address pain
• NSAIDs
• COX-2 agents
• Refer complications early
• Maintain Mobility
– Active ROM &
strengthening
• Restore proprioception
– Wobble board, minitrampoline
• Work-hardening
program or job
specific exercise
programs
• Prevent future reinjury
– Education
• Understand injury,
treatment, rehab and
prevention strategies
Upper Extremity Evaluation
1)
2)
3)
•
History
Exam
Diagnostic studies
Key is putting all
three together to
make a “total”
picture
Low Back Pain
• Most commonly seen
musculoskeletal injury
• In normal population 80%
of us will have an LBP
episode in their lifetime
• 3-4% per yr. Will be
temporarily disabled
• 1% of working population
will be permanently
disabled
Ref: www.emedicine.com/neuro/topic516.htm
Myths of Low Back Pain
• True or false:
– All people with LPB need an x-ray
– Rest is good for pain
– MRI or CT must be done to provide definitive
diagnosis
– Vast majority of patients improve in 2-6 weeks
with or without treatment (approx. 90%)
Anatomy of the Lumbar Spine
• No lateral support in
lumbar spine (>
mobility in sagittal and
coronal planes)
• Bony vertebrae
– Transverse and spinous
processes
• Intervertebral disc
– Outer annulus fibrosis
– Inner nucleus pulposus
Anatomy of the Lumbar Spine
• Anatomical
relationship between
L4, L5 and S1
Anatomy of the Lumbar Spine
• Specific nerve
roots have
specific
functions and
will elicit
specific
symptoms
Diagnosing Low Back Pain:
Sprain/Strain Injury
• Vast majority of LBP
is a sprain/strain injury
– Ligamentous
– Tendonitis
• LBP most often over
R lumbar sacral area
– Tends to be localized
– Referred pain not
typically seen
– Described as “aching”
Diagnosing Low Back Pain:
Nerve Root Compression
• Back pain due to nerve root
compression/radiculopathy
less common
– “Sciatica” is not a good term
• Sciatic nerve= combination of
tibial and peroneal nerve- forms
well outside spinal canal where
most back problems occur
Diagnosing Low Back Pain:
Nerve Root Compression
• Impingement compression pathology
of spinal nerve root
– Initial complaint may be “electric
shock down leg”
• Mechanism=  ICP due to  
intrathoracic pressure   venous
outflow from brain   ICP  
pressure on nerve from disc causing
burning/shooting pain
– Parethesias
• Numbness/tingling
– Bowel/bladder involvement
• Cauda Equina Syndrome
• Medical/surgical emergency
Diagnostic Studies for Low Back
Pain
• X-rays
– ? value
• MRI and CT scans
– Asymptomatic disc
herniations are
commonly found on
What is diagnostic
value of this?
– When should MRI or
CT be done?
Two Common Presentations of
Low Back Pain
• History:
– 38 year old male experienced the following
after lifting a 100 pound box from the floor to a
shelf at work
– 1) Localized back pain
» OR
– 2) Very specific burning pain radiating to leg
Complaint #1
• Physical exam findings
–
–
–
–
–
–
Non-specific
Reflexes normal
ROM, gait, posture
Palpation of spine
Response to light touch
Provocative testing done
• Straight leg raise
• Heel to toe walk, squat
and rise
• Palpation of sciatic notch
Complaint #1
• Diagnostic testing
– Not usually indicated
unless red flags are
present i.e. fever, wght.
loss, hx of cancer, use
of steroids etc.
• Likely diagnosis
– Low back strain/sprain
Complaint #1
• Treatment
– NSAIDs
– Physical therapy
– May need modified
duty/work restrictions
– Importance of developing
trusting relationship with
patient to optimize outcome
• Lou Millender, MD
– “Love ‘em back to
health!”
Complaint #2
• Physical exam
– Specific
– Motor weakness in
specific distribution
– Abnormal reflexes
– Sensory loss
– Provocative testing
• ? Cauda Equina
syndrome if unable to
heel toe walk or squat
• + straight leg raise
Complaint #2
• Diagnostic testing
– X-rays not useful
– MRI after 6 weeks of
conservative treatment
unless neuro symptoms
– Electrophysiology studies
• What are they
• When are they done
• What will they show
• Likely diagnosis
– Radiculopathy
Complaint #2
• Treatment
–
–
–
–
–
Most improve on own
Pain control
Physical therapy
Prednisone/epidural steroids
May need to be out of work
for 1-2 days during acute
symptoms
– Surgical intervention
– May require work
restrictions/modified duty
Provocative Testing of the
Shoulder
• Apley scratch test
– Maneuver = touch
superior/inferior aspects of
opposite scapula
– Positive result (< ROM) =
rotator cuff problem
• Neer’s test
– Maneuver = place arm in
forced flexion with arm
fully pronated
– Positive result (pain) = subacromial impingement
Neer’s
Provocative Testing of the
Shoulder
• Crossed arm test
– Maneuver = raise arm
to 90 degrees then
actively adduct armforces the acromion
into the distal end of
the clavicle
– Positive result (pain) =
disorder of
acromioclavicular joint
CROSSED ARM
Provocative Testing of the
Shoulder
• Hawkin’s test
– Maneuver = elevate arm forward
to 90 degrees while forcibly
internally rotating shoulder
– Positive result (pain) =
subacromial impingement or
rotator cuff tendonitis
• Drop arm test
– Maneuver = Passively abduct
shoulder, observe pt. lowering
arm to waist
– Positive result (arm will drop to
side) = rotator cuff tear
HAWKIN’S
Provocative Testing of the Elbow
and Hand
• Phalen’s test
– Maneuver = press back
of hands together with
wrists fully flexed,
hold 60 seconds
– Positive result
(numbness/tingling) =
carpal tunnel
syndrome, median
nerve
Provocative Testing of the Elbow
and Hand
• Tinel’s sign
– Maneuver = tap over the
carpal tunnel area (hand) or
tap ulnar notch between
olecranon process and
medical epicondyle (elbow)
– Positive result (pain,
tingling or electric sensation
in hand) = carpal tunnel
syndrome, median nerve in
hand or ulnar nerve
compromise in elbow
Case Studies
• MRI case study
– Terminology
• T1 and T2 weighting
– What to look for in the
report
• Electromyelogram
case study
– How they are done
– What to look for in the
report
References
• http://.bledsoebrace.com/education/cp03001
2.htm
• http://bledsoebrace.com/products/products.h
tm
• http://www.fpnotebook.com/ORT55.htm
• http://orthoinfo.aaos.org
References
• Karen Muller, MPT, Journal of Orthopaedic &
Sports Physical Therapy, 2000;30(3): 138-142
• The Physician and Sports Medicine:
Patellofemoral pain
• mmg.Sechrest.com
• www.kneeguru.co.uk
• Taylor, S., P.T., “Diagnosis, Management and
Treatment of Knee Disorders: The Extensor
Mechanism”, PowerPoint Presentation, New
England Baptist Hospital, 2001.