Lower Extremity Joint Exam (Part 2)

Transcript

• 00:11we're going to talk now about
• 00:13the physical examination of
• 00:14the lower extremity joints.
• 00:16The patient should be lying down
• 00:18on an examining table to get a
• 00:20good examination of the joints.
• 00:22And the patient should be undressed,
• 00:23wearing shorts or a gown so
• 00:25you can get a good examination,
• 00:27particularly of the feet and knees.
• 00:30So we're going to start with the
• 00:32feet and we shouldn't pass over
• 00:34all foot problems to podiatrist.
• 00:35You get an awful lot of information
• 00:38from examining the feet.
• 00:39So in the feet,
• 00:40we're going to look at the distal
• 00:43and proximal interphalangeal joints.
• 00:45We're going to look at the car,
• 00:47the tarsal metatarsal joints.
• 00:49We're actually going to look at
• 00:51three ankle joints and the three
• 00:54ankle joints are the tibio tail
• 00:56joint between the the tibia and
• 00:59the tailus logically enough the
• 01:01so-called sub tail joint and this
• 01:03is below the tailus and right
• 01:06here underneath the calcaneus,
• 01:08between the tailus and the calcaneus and
• 01:10finally the so-called mid tarsal joints.
• 01:12And those are all the joints between the
• 01:15tarsal bones and the metatarsal bones.
• 01:17Here in examining the foot,
• 01:20you're particularly interested
• 01:22in the interfalangeal joints and
• 01:24the metatarsal phalangeal joints.
• 01:26When you see swelling of the
• 01:28interphalangeal joints of the toes,
• 01:30think psoriatic arthritis or
• 01:32Reiter's syndrome.
• 01:34If the patient has a good deal of
• 01:36pain and the balls of their feet
• 01:38that maybe rheumatoid arthritis.
• 01:39It's the most common joint to be
• 01:42involved in rheumatoid arthritis
• 01:43we can't see them very well.
• 01:46So what we usually do is we'll
• 01:48simply press the foot like that
• 01:49see if that causes pain.
• 01:51But tenderness is not a great test,
• 01:53so I really have a hard time making
• 01:56a diagnosis of metatarsal phalangeal
• 01:58joints on the physical examination.
• 02:01Now there are a lot of abnormalities
• 02:03that occur as we age.
• 02:05Of the interphalangeal joints
• 02:06of the toes we have a clot toe.
• 02:08We have a whole variety of things,
• 02:10probably due to little abnormalities
• 02:12in the nerves and muscles down there,
• 02:15but not due to the joints.
• 02:17So you'll see a people with curved up,
• 02:18curled up toes and their joints are fine.
• 02:21That's just the changes that
• 02:23occur with aging.
• 02:24So this is what's called a bunion.
• 02:26And a bunion is caused by malalignment
• 02:29of the metatarsal bone where it
• 02:32articulates with a tarsal bone.
• 02:35Here it moves a little bit medially,
• 02:37and because it moves medially,
• 02:39the toe moves laterally,
• 02:41and this is called a hallux valgus.
• 02:44And you very often will get a
• 02:46little bit of local irritation
• 02:47over the medial aspect of the
• 02:50first metatarsal phalengeal joint.
• 02:52The treatment of this is to have a wide shoe,
• 02:54so there's no pain that occurs
• 02:57when this joint is involved.
• 03:00The ankle joints we mentioned earlier,
• 03:03the Tibio Tailor joint is here,
• 03:05the synovial pouching is here.
• 03:08And if you want to aspirate that joint,
• 03:10you go just immediately to the extensor
• 03:13helicus longest right at the level
• 03:15of the Maleoli and you point your
• 03:18needle in just a little bit Medially,
• 03:21the second elbow ankle joint which
• 03:23is not connected to the Tibio tailor
• 03:26joint is a so-called sub tailor joint.
• 03:29So the sub tailor joint is
• 03:31below the Maleoli between the
• 03:36tibia, between the tailus and the calcaneus,
• 03:40and if you want to aspirate
• 03:42fluid from that joint,
• 03:44you have to take your needle,
• 03:45go under the malleolus and you have to
• 03:50angle your needle about 45 degrees superior.
• 03:53It's actually pretty easy to tap,
• 03:55but the tibio tailor joint and the
• 03:57sub tailor joint are not connected,
• 03:59so a patient might come in after
• 04:01a hard weekend of drinking with
• 04:02a very painful swollen ankle.
• 04:04If the disease is in the sub tailor joint,
• 04:06you're not going to get anything
• 04:08when you tap the Tibio tailor joint.
• 04:10The third joint,
• 04:11which is considered an ankle joint,
• 04:13is a joint between the tarsal bones and
• 04:17the metatarsal bones in this area here.
• 04:20So the Tibio tailor joint flexes and
• 04:23extends the foot on the lower leg.
• 04:26The sub tailor joint inverts and
• 04:28everts the hind foot, OK.
• 04:30The mid tarsal joint inverts
• 04:33and everts the four foot.
• 04:36So the way in which you check the mid tarsal
• 04:39joint is you immobilize the calcaneus,
• 04:42grab the Achilles tendon and move the arm,
• 04:44I'm sorry,
• 04:45move the the foot around like that.
• 04:48So tibia, tailor,
• 04:50sub tailor and mid tarsal joint.
• 04:53There are a number of non rheumatic
• 04:57conditions that will affect the foot.
• 05:00A very common abnormality is
• 05:04so-called plantar fasciitis,
• 05:07and plantar fasciitis is caused by
• 05:10irritation of the plantar fascia,
• 05:13just as it attached to the calcaneus.
• 05:15You diagnose this by simply putting your
• 05:18hand here and moving the foot around,
• 05:21and if that causes pain here,
• 05:23that's plantar fasciitis.
• 05:24A second very common problem in the foot
• 05:28is what's called Achilles tendonitis,
• 05:30and that's irritation here.
• 05:31And again that's usually diagnosed
• 05:33because of local tendonness
• 05:35right over the Achilles tendon.
• 05:37So for the foot,
• 05:38we are particularly interested in any
• 05:40involvement of the interphalangeal joints.
• 05:42We have to recognize that curled
• 05:44up toes or something that occur
• 05:45with a lot of people as they age
• 05:47don't necessarily mean arthritis.
• 05:49A bunion does not mean arthritis.
• 05:52The metatarsal phalangeal joint,
• 05:54although very commonly involved
• 05:56in rheumatoid disease is hard
• 05:58to examine in the foot.
• 06:00But you can examine the tibio tailor joint,
• 06:03the sub tailor joint and
• 06:05the mid tarsal joint.
• 06:06And don't forget about plantar
• 06:09fasciitis and Achilles tendonitis.
• 06:12So examining the knee,
• 06:15orthopedic surgeons have thousands of
• 06:17ebonyms about problems in the knees.
• 06:19I would like you to focus on several
• 06:22very simple aspects of the knee.
• 06:24First of all,
• 06:24look at the patient when
• 06:26he or she is standing.
• 06:27If the patient is bolated,
• 06:29that patient has in Latin what's called
• 06:33genovaris and that's a very common
• 06:35sign of generalized osteoarthritis.
• 06:37If the patient has not
• 06:39need socalled genovalgus,
• 06:41that's a common abnormality in
• 06:43patients with inflammatory arthritis
• 06:46such as rheumatoid arthritis.
• 06:48The distinction between the
• 06:52capsule of the knee and burst
• 06:54of the knee is absolutely key.
• 06:56So I have a model here that helps
• 06:58us when we examine in the knee and
• 07:01the model tells us about the Patella
• 07:04about the medial and lateral
• 07:06collateral ligaments.
• 07:07These ligaments here, the menisci,
• 07:09this little pad in here,
• 07:11but it also demonstrates to us
• 07:13where the synovial capsule is.
• 07:15So the capsule is capsule is
• 07:18above medial and lateral to
• 07:20the kneecap or the Patella.
• 07:22So swelling here is the knee capsule.
• 07:25Swelling here the so-called the pre
• 07:27Patella Bursitis or infra Patella
• 07:30Bursitis that if you have swelling
• 07:32right on top of the kneecap or
• 07:35swelling right below the kneecap
• 07:36that's Bursitis that's not arthritis.
• 07:39So the 1st and most important
• 07:42part of the knee examination is
• 07:44to check for fluid so the again
• 07:47the knee capsule extends superior,
• 07:49medial and lateral to the Patella.
• 07:52So what you want to do is take
• 07:54your index finger and thumb put
• 07:55it on either side of the Patella
• 07:57right here and then take your other
• 08:00hand and press it firmly down
• 08:02on the Super Patella space.
• 08:04So if you feel pressure coming down here,
• 08:07that's perfectly normal, no fluid.
• 08:10If you feel the pressure pushing
• 08:12out against your index finger and
• 08:15thumb from inside the knee area,
• 08:17that's a sign of extra fluid.
• 08:19So you press here and see
• 08:20where you feel the pressure.
• 08:21If you feel it here,
• 08:22it's a it's this extra fluid in the knee.
• 08:24If you feel it here, that's perfectly normal.
• 08:27Now,
• 08:27we can sometimes use what's called
• 08:30a positive bold sign if there's
• 08:32a moderate amount of fluid.
• 08:33So if there's 50 or 60 cc's
• 08:35of fluid in the knee,
• 08:36you're not going to get a positive bold sign.
• 08:38But if it's 10/15/20 cc's, you may get one.
• 08:41So how do we do that?
• 08:42Well,
• 08:42you can see here there's a dimple
• 08:44on the medial aspect of the knee.
• 08:46If that dimple is filled in,
• 08:49we'll massage it somewhat vigorously
• 08:51and then press down laterally.
• 08:54And if we see a bulge or fluid wave here,
• 08:57that's a sign of extra fluid in the knee.
• 09:00So looking for fluid in the
• 09:02knee is absolutely key.
• 09:04I'm looking for specific
• 09:05problems in the knee,
• 09:07probably the one I'm most interested in.
• 09:08If someone's had a trauma,
• 09:10someone comes in from a soccer game or
• 09:12skiing and has had trauma to the knee.
• 09:15I'm particularly interested in a
• 09:17torn medial collateral ligament.
• 09:19So the way in which we test the
• 09:21medial collateral ligament is we
• 09:22bend the knee about 30 degrees
• 09:24and the reason we bend the knee
• 09:26is a quadriceps is an excellent
• 09:28stabilizer of the knee.
• 09:29We want to get rid of that
• 09:31stabilizing effect.
• 09:32So we have the naked ligament
• 09:33that we're looking at.
• 09:34I then take the palm of my hand
• 09:37and I put my palm here on the
• 09:39lateral aspect of the knee and
• 09:42then I simply pull in this fashion.
• 09:44And if there's a swinging gait here,
• 09:47that's a sign of a medial
• 09:49collateral ligament tear.
• 09:50That's important because when you have
• 09:52a medial collateral ligament tear,
• 09:54you often have associated with
• 09:56that the so-called vicious triad
• 09:58that is meniscual disease
• 10:00and anterior crusade disease.
• 10:02So that's the way you look for
• 10:04medial collateral ligament tears.
• 10:06Now, if you're looking for meniscule disease,
• 10:10this is a little more difficult.
• 10:13The classic maneuver looking for meniscal
• 10:16disease or internal derangements is
• 10:18what's called the McMurray sign.
• 10:20And you combine extension with rotation.
• 10:23But the sensitivity and specificity
• 10:25of that test is not terrific.
• 10:27But here's how to do it.
• 10:28So you bend the knee,
• 10:30you put a medial pressure on the knee,
• 10:33you push the knee like this,
• 10:35and you combine rotation of the
• 10:38ankle with extension of the knee,
• 10:41and that puts strain on the
• 10:44medial compartment.
• 10:45And if you get a popping or
• 10:47a pain when you do that,
• 10:49that's a sign of a meniscal tear.
• 10:53One of the structures that can
• 10:55occasionally give you knee pain
• 10:57is the socalled anserene Bursa.
• 11:00It used to.
• 11:01There's a When the old anatomist
• 11:02looked at this and I thought
• 11:04it looked like a goose's foot,
• 11:05they called the Pez answering.
• 11:07So the answer reimburser is
• 11:09right at the insertion of the
• 11:11medial hamstring muscles.
• 11:12So you take your hand,
• 11:14you follow the medial hamstring muscles
• 11:16down the leg until it inserts in the tibia,
• 11:19just about two finger
• 11:21breasts below the joint line.
• 11:23That's often A cause of pain.
• 11:25You can't see this Bursa,
• 11:27but you find exquisite tenderness
• 11:29when you palpate this bursar
• 11:31on physical examination.
• 11:33Now,
• 11:33one of the compartments of the knee
• 11:36that frequently causes knee pain
• 11:38is the compartment between the
• 11:40kneecap or Patella and the femur.
• 11:42There are three compartments in the knee,
• 11:43medial compartment, lateral compartment,
• 11:46and so-called patello femoral compartment.
• 11:48The way way in which we test the
• 11:51patello femoral compartment is
• 11:53we take our fingers,
• 11:54put them right on the superior
• 11:56margin of the Patella.
• 11:57Remember, the Patella is a sesamoid bone,
• 12:00a bone inside a muscle.
• 12:01So we asked the patient to
• 12:03press their knee into the bed.
• 12:04So when Andrea does that,
• 12:06you can see she contracts her quadriceps.
• 12:08So she's extending her knee and
• 12:10she's contracting her quadriceps.
• 12:12And when that happens,
• 12:13the Patella moves superiorly,
• 12:14So this muscle contracts the
• 12:16bone in the muscle moves,
• 12:18moves superiorly, so we use that.
• 12:20I take my finger,
• 12:21put it on top of the Patella.
• 12:23I ask her to press her knee into the bed,
• 12:25and if that reproduces her pain,
• 12:28that's a sign that we're probably
• 12:30do it dealing with Patello
• 12:32femoral irritation as the cause
• 12:34of the patient's knee pain.
• 12:36So the key thing about examining a
• 12:38knee is you want to look and see if
• 12:40there's any signs of fluid in the knee.
• 12:42You want to check for ligamentous tears.
• 12:44You want to check the Patello
• 12:46femoral compartment in the knee.
• 12:47You want to look for the Bursa of the knee.
• 12:49Particularly look for the answering Bursa,
• 12:52which is a common source of knee pain.
• 12:55So a very important joint to
• 12:58examine is a hip.
• 13:00The reason for that is that
• 13:01hip disease can be
• 13:02felt in four places, the groin,
• 13:04the thigh, the knee or the buttock.
• 13:06So back pain can be due to hip disease.
• 13:08So the patient should be lying down,
• 13:10should be relaxed, should be covered
• 13:12shorts or a sheet between the legs.
• 13:15And then you relax the patient and
• 13:17you're checking passive range of motion,
• 13:20analogous to what we did in the
• 13:22glenohumeral joint of the shoulder.
• 13:23So we take one hand and put it on
• 13:25the lateral aspect of the pelvis.
• 13:27We relax the patient,
• 13:28we have one hand on the pelvis, we take
• 13:31the leg and we very gently abduct the leg.
• 13:34And we should be able to abduct it to
• 13:37about 40 degrees before the pelvis tilts,
• 13:39so about halfway through a right angle,
• 13:41and that's normal.
• 13:42So this is normal. Abduction.
• 13:44I then take the leg, take the knee,
• 13:47bend the knee, bend the hip,
• 13:49and then take my heel and
• 13:50I move it immediately,
• 13:52and that's called lateral rotation.
• 13:55Arbitrarily.
• 13:55That's what that maneuver is called,
• 13:57and it should be 50 to 60 degrees.
• 14:00I then move the leg laterally,
• 14:02which is called medial rotation,
• 14:04and it should be roughly 15 to 20 degrees.
• 14:07So if there is full passive range of motion,
• 14:1140 degrees of abduction,
• 14:1360 degrees of internal rotation,
• 14:1520 degrees of internal rotation of the hip,
• 14:17it's highly unlikely that the hip
• 14:20is the cause of the patient's groin,
• 14:23back, thigh or knee pain.
• 14:25If the range of motion is limited,
• 14:27then you have a few more things to do,
• 14:29but it's a very important screening test,
• 14:30very easy to do.
• 14:32Any patient with back pain.
• 14:33You should always examine the hip.
• 14:35You just lie them down and you
• 14:36passively do it and it gives you
• 14:38an awful lot of information.
• 14:44There are many mechanical
• 14:45problems that can occur in the
• 14:46fore foot that are not arthritis.
• 14:48A bunion, cloroto, maloto,
• 14:50hammertoe are all due to neuropathic
• 14:52problems, not arthritis.
• 14:54If you see involvement of the
• 14:56interphalengial joints of the toes,
• 14:58think psoriatic arthritis
• 14:59or Reiter's syndrome.
• 15:00The metatarsal phalengial joint is
• 15:03actually the most common joint to be
• 15:06involved in inflammatory arthritis.
• 15:08There are three joints of the ankles,
• 15:09A Tibio Tailor joint.
• 15:10The capsule is over the anterior
• 15:12aspect of the ankle and that
• 15:14flexes and extends the foot.
• 15:16The subtala joint is a very separate joint.
• 15:19The capsule is below the maleal eye and
• 15:21that inverts and inverts the hind foot.
• 15:23The metatarsophyllingeal joint.
• 15:24The capsule is over the forefoot and
• 15:27it inverts and inverts the forefoot.
• 15:29Examining the knee.
• 15:31Remember,
• 15:31the synovial capsule is superior
• 15:33medial and lateral to the Patella.
• 15:35We find diffusions by finding pressure
• 15:38coming out against our fingers as we
• 15:41palpate down on the Super Patella region.
• 15:44Positive bold sign is when a fluid
• 15:46wave is produced in the medial
• 15:48region when pressure is placed on
• 15:50the lateral aspect of the knee.
• 15:52You look at the medial collateral
• 15:54ligament by stressing the knee
• 15:56with a palm of the hand,
• 15:57serving as a fulcrum of that movement.
• 16:00You test for medial meniscal tears by
• 16:03combining extension and rotation of the knee,
• 16:06and you test for patello femoral
• 16:08disease by putting pressure on the
• 16:10superior border of the Patella
• 16:12and asking the patient to contract
• 16:14the quadriceps by pushing the leg
• 16:16into the examining table.
• 16:17Hip range of motion is extremely important.
• 16:20The patient must be supine.
• 16:22You place your hand over the lateral
• 16:24aspect of the pelvis and then
• 16:26a B duct the leg.
• 16:28When the pelvis moves,
• 16:29that's abduction and usually it's 40 degrees.
• 16:32You flex the hip and externally
• 16:34or loudly rotate the hip.
• 16:35You should be able to get 60
• 16:37degrees and you flex the hip and
• 16:40internally immediately rotate the
• 16:42hip and you should get 20 degrees.
• 16:44So the exam is very simple,
• 16:46doesn't take much time,
• 16:47but can be invaluable in trying to sort
• 16:50out what's going on with the patient.