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The Musculoskeletal Examination in the Elderly. PPC 1-30-2007 10:00 Block 3- 2006 R Williams, MD. Objectives. Review the adult musculoskeletal examination Classify the common musculoskeletal conditions and risks inherent with aging

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The Musculoskeletal Examination in the Elderly

PPC 1-30-2007 10:00

Block 3- 2006

R Williams, MD


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Objectives

  • Review the adult musculoskeletal examination

  • Classify the common musculoskeletal conditions and risks inherent with aging

  • Identify methods of examination of frail elderly individuals

  • Recognize the value as well as the risk of OMM in the elderly population


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Physical examination of the knee

Exam Overview

  • A complete knee examination is always done for a knee complaint or complete physical exam.

  • Inspect your knee visually for redness, swelling, deformity, or skin changes.

  • Feel your knee (palpation) for warmth or coolness, swelling, tenderness, blood flow, and sensation.

  • Test your knee's range of motion and listen for sounds.


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Physical examination of the knee

  • Exam your knee ligaments, which stabilize the knee. Tests include:

    • The Valgus and Varus tests, which check the medial and lateral collateral ligaments.

    • The posterior drawer test, which checks the posterior cruciate ligament .

    • The Lachman test, which checks the anterior cruciate ligament (ACL)

  • A McMurray test may be done if you suspect a problem with the menisci based on your medical history and the above examinations.



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General Exam (compare with less affected knee)

Observation

Ecchymosis

Knee Effusion with obscured landmarks

Knee Effusion Causes

Ballottable Patella Sign

Knee Bulge Sign

Previous surgical scars

Knee resting position

Quadriceps muscle atrophy

Evaluate Vastus Medialis Obliquus specifically

Atrophy often on side of ligamentous injury

Tenderness to Palpation

Patella

Tibial tubercle

Patellar tendon

Quadriceps tendon

Joint line

Normal Range of Motion

Flexion: 135 degrees

Extension: 0 to 10 degrees above horizontal plane

Patellofemoral

Quadriceps Femoris Muscle Angle (Q Angle)

Patella tracking with quadriceps contraction

Evaluate for smoothness of motion and crepitation

Knee exam


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Patellar Apprehension Test

Evaluates for Patella Subluxation

Anterior Cruciate Ligament (ACL) Stability Tests

Lachman Test (most sensitive)

Knee Anterior Drawer Test

Pivot Shift Test (MacIntosh Test)

Posterior Cruciate Ligament (PCL) Tests

Knee Posterior Drawer Test

PCL Sulcus Test

PCL Sag Test

Collateral ligament evaluation

Knee Valgus Stress Test (Medial collateral ligament)

Knee Varus Stress Test (Lateral collateral ligament)

Meniscus Evaluation

McMurray's Test

Apley's Compression Test and Apley's Distraction Test

Bounce Test

Standing evaluation

Balanced weight on each leg

Genu Varum or Genu Valgum deformity

Gait analysis

Patella baja or patella alta deformity

Hip, Knee, and ankle alignment

Knee exam



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  • Assessment of quadriceps strength. The examiner places his hands over the distal leg and asks the patient to try to straighten out their leg.Assessment of gross quadriceps strength by the physical exam is not as accurate when done by machines. Subtle differences in strength or fatigue may not be accurately determined.


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The shoulder exam hands over the distal leg and asks the patient to try to straighten out their leg.


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The four major muscles of the rotator cuff hands over the distal leg and asks the patient to try to straighten out their leg.

  • Rotate the humerus and properly orient the humoral head in the glenoid fossa (socket).

  • The tendons of these four muscles merge, forming a cuff around the glenohumeral joint.

  • Supraspinatus: abducts the humeral head and acts as a humeral head depressor

  • Infraspinatus: externally rotates and horizontally extends the humerus

  • Teres minor: externally rotates and extends the humerus

  • Subscapularis: internally rotates the humerus


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Subscapularis (Internal rotation) hands over the distal leg and asks the patient to try to straighten out their leg.

  • Technique 1: Tennis Forehand

    • Start with arm at side, elbow flexed 90-100 degrees

    • Internal rotation against resistance

      • Tennis Forehand

  • Technique 2: Apley's Scratch Test Modification

    • Hand scratching between scapulae

    • Move hand away from back


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Teres Minor and Infraspinatus (External Rotation) hands over the distal leg and asks the patient to try to straighten out their leg.

  • Start with arm at side, elbow flexed 90-100 degrees

  • External Rotation against resistance (Tennis backhand)


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Supraspinatus Test hands over the distal leg and asks the patient to try to straighten out their leg.

  • Hold arms to side as if holding cans bilaterally

    • Empty Cans test (original test)

      • Wrists pronated as if emptying cans

    • Full Cans Test

      • Wrists supinated as if holding cans upright

      • May be more specific for Supraspinatus impingement

  • Hold arm abducted at 50 degrees against resistance

  • Interpretation

  • Arm weakness is specific to Supraspinatus impingement


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Bicipital Tendon hands over the distal leg and asks the patient to try to straighten out their leg.

  • Technique

  • Start

    • Arm forward flexed 50 degrees at shoulder

    • Hand Supinated (palm up)

    • Elbow flexed 15 degrees

  • Maneuver

    • Forward flex against resistance at forearm

  • Interpretation

  • Pain sensitive for bicipital Tendonitis

  • Suggests SLAP lesion of long head of biceps


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FIGURE 1. Anatomy of the shoulder and rotator cuff, showing (left) anterior and (right) posterior view


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Ligaments of the Glenohumeral Joint. (

A joint capsule is a watertight sac that surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments that connect the humerus to the glenoid.. These are the glenohumeral ligaments (GHL) Another ligament links the coracoid to the acromion - coracoacromial ligament (CAL). This ligament can thicken and cause Impingement Syndrome Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony ridge on the scapula - coracoclavicular ligaments (CCL) Ligaments of the Shoulder Complex:

  • CCL - coracoclavicular ligaments

  • CAL - coracoacromial ligaments

  • SGHL - Superior GlenoHumeral Ligament

  • MGHL - Medial GlenoHumeral Ligament

  • IGHL - Inferior GlenoHumeral Ligament


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Normal Rotator Cuff MRI (

  • Notice purely black signal at the tip of the red arrow


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Torn Rotator Cuff MRI (

  • Notice white signal within black signal at the tip of the red arrow


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Shoulder strength testing (

Rotator cuff

Supraspinatus




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Range of Motion (

External rotation

Internal rotation

Forward flexion




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Hip Pain inguinal ligament--a possible site of nerve compression


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Hip Fractures inguinal ligament--a possible site of nerve compression


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FABER Test (Hips/Sacroiliac Joints) inguinal ligament--a possible site of nerve compression

  • FABER stands for Flexion, ABduction, and External Rotation of the hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems.

  • Ask the patient to lie supine on the exam table.

  • Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip).

  • Pain in the groin area indicates a problem with the hip and not the spine.

  • Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest.

  • Pain in the sacroiliac area indicates a problem with the sacroiliac joints.


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Treatment for hip arthritis inguinal ligament--a possible site of nerve compression

  • Weight LossProbably one of the most important, yet least commonly performed treatments. The less weight the joint has to carry, the less painful activities will be.

  • Activity ModificationLimiting certain activities may be necessary, and learning new exercise methods may be helpful. Aquatic exercise is an excellent option for patients who have difficulty exercising.

  • Walking AidsUse of a cane or a single crutch is the hand opposite the affected hip will help decrease the demand placed on the arthritic joint.

  • Physical TherapyStrengthening of the muscles around the hip joint may help decrease the burden on the hip. Preventing atrophy of the muscles is an important part of maintaining functional use of the hip.


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Treatment for hip arthritis inguinal ligament--a possible site of nerve compression

  • Anti-Inflammatory Medications Anti-inflammatory pain medications (NSAIDs) are prescription and nonprescription drugs that help treat pain and inflammation.

  • Joint Supplements (Glucosamine)Glucosamine appears to be safe and might be effective for treatment of osteoarthritis, but research into these supplements has been limited.

  • Total Hip Replacement SurgeryIn this procedure the cartilage is removed and a metal & plastic implant is placed in the hip.


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Tools inguinal ligament--a possible site of nerve compression

  • Activities of Daily Living

  • Tinetti Gait and Balance Tool

  • Get up and go


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Activities of Daily Living inguinal ligament--a possible site of nerve compression

  • Based on 6 criteria

    • Bathing with sponge, bath, or shower

    • Dressing

    • Toilet Use

    • Transferring (in and out of bed or chair)

    • Urine and Bowel Continence

    • Eating

  • Each criteria is graded on level of dependence

    • Performs independently

    • Performs with assistance

    • Unable to perform


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Tinetti Gait and Balance inguinal ligament--a possible site of nerve compression

  • 16 items, including:

    • Sitting balance

    • Attempts to arise

    • Standing balance

    • Balance with a nudge

    • Turning 360 degrees

    • Initiation of gait

    • Step length and height

    • Step symmetry

    • Step continuity

    • Walking stance


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Get up and go inguinal ligament--a possible site of nerve compression

1. Rise from sitting position

2. Walk 10 feet

3. Turn around

4. Return to chair and sit down

Interpretation

Patient takes <20 seconds to complete test=Adequate for independent transfers and mobility

Patient requires >30 seconds to complete test= Suggests higher dependence and risk of falls


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Hand OA inguinal ligament--a possible site of nerve compression

  • Heberden's nodes

    • bony enlargements of the distal interphalangeal joints

    • are the most common form of idiopathic OA.

  • Bouchard's nodes

    • proximal interphalangeal joints

  • Often, these nodes develop gradually, with little or no discomfort.

  • However, they may present acutely with pain, redness, and swelling, sometimes triggered by minor trauma.

  • Gelatinous dorsal cysts filled with hyaluronic acid may develop at the insertion of the digital extensor tendon into the base of the distal phalanx.


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MCP inguinal ligament--a possible site of nerve compression

PIP

DIP

Note the involvement of the DIP (Distal Interphalangeal) followed by PIP (Proximal Interphalangeal) and relative sparing of the MCP (Metacarpal Phalangeal) joints.

Bouchard’s node

Heberden’s node


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Swelling, tenderness, and crepitus on movement of the joint are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and swan-neck deformity of the thumb.

OA of the base of the thumb


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Risk Factors for Osteoarthritis are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Age- the most powerful risk factor

    • By age 65, 68% have radiographic evidence of OA

  • Female sex- especially with hand and knee OA

  • Race- not know whether this is genetic or related to life-style differences

  • Genetic factors- not well worked out, but there is a correlation

  • Joint trauma

  • Repetitive stress

  • Obesity- highest correlation with knee OA


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Spine OA are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Degenerative disease of the spine can involve the

    • apophyseal joint

    • intervertebral disks

    • paraspinous ligaments.

  • Spondylosis refers to degenerative disk disease.

  • The diagnosis of spinal OA should be reserved for patients with involvement of the apophyseal joints and not only disk degeneration.

  • Symptoms of spinal OA include

    • localized pain and stiffness

    • Nerve root compression by an

      • osteophyte blocking a neural foramen

      • prolapse of a degenerated disk

      • or subluxation of an apophyseal joint may cause radicular pain and motor weakness.


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Degenerative changes in the spine- Definitions: are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Apophyseal joint- the joint around a bone that has no independent ossification

  • Spondylosis- ankylosis (stiffening) of the vertebrae (this term is often used very generally to refer to any degenerative back problem)

  • Spondylolysis- degeneration of the articulating part of the vertebrae (the classic OA change)

  • Spondylolisthesis- forward movement of the body of one of the lower vertebrae on the vertebrae below it

  • Spondylitis- inflammation of one or more of the vertebral bodies (infection [TB] or inflammatory disease [RA])


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Knee OA are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

OA of the knee may involve the medial or lateral femorotibial compartment and/or the patellofemoral compartment.

Palpation may reveal bony hypertrophy (osteophytes) and tenderness.

Effusions, if present, are generally small.

Joint movement commonly elicits bony crepitus.

OA in the medial compartment may result in a varus (bow-leg) deformity; in the lateral compartment it may produce a valgus (knock-knee) deformity.

A positive "shrug" sign (pain when the patella is compressed manually against the femur during quadriceps contraction) may be a sign of patellofemoral OA.


Background information l.jpg
Background Information are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Osteoarthritis is the most common type of arthritis

  • Degenerative joint disease is a term synonymous with osteoarthritis.

  • Osteoarthritis is a joint disease that primarily affects the cartilage.

  • Cartilage acts as a lubricating surface and a “shock absorber” for bones.

  • In osteoarthritis the layer of cartilage breaks down and wears away.


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Lifetime Changes in Bone Mass are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

Risk factors: low calcium intake, smoking, alcoholism, certain medications.

Both men and women lose predominantly cancellous (vertebral) bone.


Epidemiology of osteoporosis fractures l.jpg
Epidemiology of Osteoporosis Fractures are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • High prevalence

    • 1.25 million female & 500,000 male hip fractures worldwide (1990)

    • 250,000 hip & 500,000 vertebral fractures in U.S. annually

  • Serious consequences

    •  quality of life, function, independence

    •  morbidity & mortality (50% of women do not recover prior function after hip fracture; 20% excess mortality in year after hip fracture)

  • Costs

    • > $14 billion in U.S.


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Vertebral Fractures are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Asymptomatic (the majority)

    • Diagnosed by spinal radiographs

    •  kyphosis or  height

    • Chronic back pain due to spinal changes that occur with vertebral compression

  • Symptomatic

    • Pain usually lasts 2 to 4 weeks

    • Can be debilitating


Omm in the frail elderly l.jpg
OMM in the frail elderly are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • The basic tenets of Geriatric Medicine and of Osteopathic Medicine are very similar

    • Function

    • Multidisciplinary, holistic approach

  • No absolute contraindication based on age alone

  • Individualize

  • Allow your examination to guide you

  • OMT is, in many cases, safer that other therapies we use on a daily basis


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OMM in the frail elderly are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Be prepared to “adjust” your approach and expectations to fit the special needs of the population

  • Clinically apparent osteoporosis should serve to discourage the use of certain high-thrust, high-velocity techniques

  • Those with high risk of stroke should be approached more cautiously


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On the other hand… are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • Range of motion, respiratory, muscle energy, myofascial techniques are particularly well suited to the geriatric population

  • The judicious use of these techniques might serve to provide relief without the use of potentially dangerous medications

  • VCOM plans to be a leader in gaining new knowledge concerning the indications (and contraindications) of OMT in the elderly


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  • http://medicine.ucsd.edu/clinicalmed/Joints.html are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the first metacarpophalangeal joint and

  • http://www.dartmouth.edu/~anatomy/knee/index.html

  • http://www.dartmouth.edu/~anatomy/knee/radiographs/index.html


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