PALPATION (TENDERNESS)

Lateral malleolus

• Fractured fibula; ligament tear

• Ankle X-ray (three views) if point tenderness OR unable to bear weight
  
• Initial talus fracture X-ray may be (-)
  
• See section on fractures and splinting

Length of fibula

• Maisonneuve fracture

Medial malleolus

• Fractured tibia; ligament tear

Base fifth MT

• Fracture

Navicular bone

• Fracture

Medial joint line

• Eversion ankle sprain
  
• Deltoid ligament injury
  
• Posterior tibialis tendon injury

• PRICEMMMS
  
• Ankle stirrup brace
  
• Confirm ligament injury with corresponding provocative test
  
• Osteochondritis dissecans is a “do not miss” diagnosis

Anterior joint line

• Anterior capsule sprain
  
• Anterior impingement
  
• Anterior tibialis injury
  
• Syndesmosis tear

Lateral joint line

• Inversion ankle sprain
  
• ATFL, CFL, PTFL tear
  
• Peroneal tendon subluxation
  
• Osteochondritis dissecans

ROM

Dorsiflexion

• Anterior tibialis tendon

• Test active, passive, and resisted ROM
  
• Weakness can persist for years if no rehabilitation

Plantarflexion

• Achilles tendon

Plantarflex eversion

• Peroneal brevis tendon

Plantarflex inversion

• Posterior tibialis tendon

PROVOCATIVE TESTS

Anterior drawer

• ATFL tear

• Compare to normal side; should be <10° difference
  
• Indicates leg instability
  
• Asymmetry may persist long after injury and be a clue to a prior old injury

Passive eversion

• Deltoid ligament tear

Passive dorsiflex inversion stress test

• CFL tear

Passive plantarflex inversion stress test

• ATFL tear

Syndesmosis squeeze

OR

Passive dorsiflexion external rotation

• High ankle sprain
  
• Interosseous ligament injury
  
• Tibiofibular ligament injury
  
• Fracture

• Ankle stirrup “air cast” compression worn 24 hr/d for 4 wk
  
• If medial widening >4 mm between talus and medial malleolus → may require surgery

Peroneal tendon subluxation

• Resisted dorsiflex eversion → attempt to push peroneal tendon over lateral malleolus

• → Orthopedic consult

Ligament tear

Minimal

Partial

Complete

Loss of function

Minimal

Some

Great

Pain

Minimal

Moderate

Severe

Swelling

Minimal

Moderate

Severe

Ecchymoses

No

Common

Yes

Weight-bearing

Normal

Partial

None

PALPATION (TENDERNESS)

Swelling

• If etiology unclear or Erythema, warmth → R/o septic joint with arthrocentesis
  
• Intra-articular vs. localized
  
• Hemarthrosis → fracture, ACL injury, patellar dislocation, bleeding disorder, meniscus

• Arthrocentesis as indicated (not for acute hemarthrosis)
  
• PRICEMMMS Identify and treat etiology (see below)

Patella

• Patellar dislocation
  
• Fractured patella

• Patellar stabilizing brace with buttress

PALPATION (TENDERNESS)

Femoral condyle

• Osteochondral fracture
  
• OCD (most commonly medial)
  
• Patellar dislocation (pain at adductor tubercle)

• X-ray for diagnosis

Medial joint line

• IT band (lateral)
  
• MCL injury
  
• Meniscus tear

• Confirm meniscus tear with MRI MCL hinged knee brace
  
• PRICEMMMS

Lateral joint line

• Meniscus tear

Tibial tubercle

• Osgood-Schlatter
  
• Fracture

• See section on fracture below

Pes anserinus bursa

• Semitendinosus, sartorius, gracilis all insert at pes anserinus

• Overuse injury; treat accordingly
  
• Examine the hip

Gerdy’s tubercle

• IT band tendonitis

• Foam roller, PT, ICE
  
• Examine the hip

ROM

Limited flexion

• Meniscus tear
  
• Intra-articular effusion

• PT for stretching and passive range of motion exercises
  
• Correlate with injury

Limited extension (+bounce home test)

• Meniscus tear
  
• Chondral contusion from hyperextension

PROVOCATIVE TESTS

Valgus stress: Twice, 0° and 30°

• MCL injury
  
• ACL tear if opens up at 0°

• All treated with a hinged knee brace
  
• Grade I: Tender, but no laxity on stress
  
• Grade II: Laxity, but with firm end point
  
• Grade III: No end point

Varus stress: Twice, 0° and 30°

• Lateral collateral ligament of knee tear
  
• Has natural laxity → compare with opposite side
  
• Usually associated with PCL injury

Anterior drawer

• ACL tear
  
• Confirm with pivot shift
  
• “Kissing contusion“ (femur and tibia) on MRI
  
• May be associated with meniscus and MCL injury

• Determine grade as I, II, or III
  
• X-ray to r/o fracture
  
• MRI → if ⊕ tear then consider orthopedic surgery consultation for repair, especially if meniscus tear also present
  
• Strengthen hamstring
  
• No sports until repaired and/or rehabilitated

Lachman

Posterior drawer

• PCL injury; also look for sag

• Can heal without surgery

PROVOCATIVE TESTS

McMurray/Modified McMurray

• Meniscus tear

• Non–weight-bearing
  
• Hinged knee brace
  
• MRI to confirm

Bounce home

• Meniscus tear
  
• MCL injury if pain along MJL

Apprehension test

• Patellar dislocation

• Vastus medialis oblique strengthening
  
• Patellar stabilizing brace

PALPATION (TENDERNESS)

All shoulder evaluations should begin with a head and neck exam to rule out cervical nerve entrapment or radiculopathy to explain pain or weakness.

Clavicle

• Fracture

• Sling for 4 wk.
  
• Weight training at 6-8 wk; no contact sports for 3 mo (see upper extremity section)

• Acromioclavicular separation

• Graded 1–5.
  
• Surgery for grade 4 or 5.
  
• Sling as needed.

Scapula

• Fracture

• Ortho consult if fracture.

Anterior joint line

• Anterior dislocation
  
• Labral tear
  
• Anterior impingement
  
• Biceps tendonitis
  
• Biceps rupture
  
• Contusion

• Correlate with history and provocative testing (see below)
  
• Sling
  
• PT

Posterior joint line

• Posterior dislocation
  
• Labral tear
  
• Posterior impingement

Long head biceps

• Biceps tendonitis
  
• Biceps rupture
  
• Contusion

• Sling
  
• Biceps strengthening
  
• PT

ROM

Forward flexion: (normal 160°–180°)

• Biceps
  
• Anterior deltoid
  
• Coracobrachialis
  
• Pectoralis major

• Shoulder joint similar to a large golf ball balanced on a small tee, providing wide ROM at the expense of stability
  
• Perform active and resisted ROM
  
• Perform passive ROM if ↓ active ROM
  
• View from behind for aberrant “scapular dyskinesis” motion
  
• Adolescents do not tear the rotator cuff unless there is a high-energy trauma
  
• If limited painful ROM, consider adhesive capsulitis
  
• If ↓ internal rotation, suspect posterior impingement
  
• PT for recovery

Extension: (normal 40°–60°)

• Triceps
  
• Posterior deltoid
  
• Teres major and minor

Abduction: (normal 160°–180°)

• Supraspinatus, first 30°
  
• Mid-deltoid, 30° to 90°
  
• Serratus anterior
  
• Trapezium, 90° to 180°

Internal rotation:

• Subscapularis (at 0° abduction)
  
• Anterior deltoid (at 0-80° abduction)
  
• Pectoralis major (at 90° abduction, decreasing to 45°)

External rotation :

• Infraspinatus (at 0° abduction)
  
• Posterior deltoid (at 45-90° abduction)
  
• Teres minor (at 90-110° abduction)

PROVOCATIVE TESTS

Hawkins impingement

• Subacromial bursitis
  
• Rotator cuff tendonitis

• Relative rest, ice
  
• Rotator cuff strengthening, PT
  
• Treat scapular dyskinesis

O’Brien’s

• Labral tear

• MRI with intra-articular gadolinium

Speed’s

• Long head biceps tendonitis

• Rest, ice, strengthen

Cross arm adduction

• Acromioclavicular separation
  
• Acromioclavicular arthritis

• Sling for 2–4 wk

Sulcus sign

• Multidirectional instability

• No contact sports
  
• No over-the-head activity
  
• Rotator cuff strengthening, PT
  
• Sling, if needed
  
• X-ray to check for Hill-Sachs/Bankart

Apprehension sign

• Anterior subluxation
  
• Anterior dislocation

Anterior instability

Fowler’s relocation

• Posterior instability

Posterior subluxation

PALPATION (TENDERNESS)

The ulnar, median, radial, anterior interosseous, and posterior interosseous nerves are all at risk for compression at the elbow; therefore, a full neurological exam is important.

Lateral epicondyle

• Lateral epicondylitis

• See provocative test below

Medial epicondyle

• Medial epicondylitis
  
• Apophysitis
  
• Fracture
  
• UCL tear/injury

• See provocative test below
  
• X-ray, bilateral elbow
  
• MRI with intra-articular gadolinium for UCL injury

Biceps tendon

• Distal biceps rupture

• Ortho consult

Olecranon

• Fracture or apophysitis
  
• Bursitis

• X-ray

Supracondylar

• Fracture

• X-ray

Ulna

• Fracture

• X-ray

Radial head

• Fracture
  
• Subluxation (nursemaid’s)

• X-ray
  
• Reduce the radial head (subluxation)

Radius

• Fracture

• X-ray

Capitellum

• OCD

• X-ray

Ulnar gutter

• Cubital tunnel syndrome

• EMG, evaluate UCL

ROM

• Biceps
  
• Brachioradialis

Pain with extension

• Triceps

Pain with supination

• Biceps
  
• Supinator
  
• Lateral epicondylitis

Pain with pronation

• Pronator teres
  
• Pronator quadratus
  
• Medial epicondylitis
  
• Pronator mass syndrome

PROVOCATIVE TESTS

Valgus stress: Elbow at 15°–30° with arm abducted to 90°

• UCL tear if opens, usually seen in baseball pitchers
  
• ⊕ Milking maneuver

• No pitching
  
• MRI

Varus stress

• Lateral ligament complex

• Conservative management

Pain with:

• Resisted wrist extension
  
• Resisted extension 3rd digit
  
• Passive wrist flexion
  
• Resisted supination

• Lateral epicondylitis

• Counterforce elbow brace
  
• Relative rest
  
• Eccentric strengthening
  
• Passive stretching
  
• Consider injection of steroid, lidocaine, or platelet-rich plasma

Pain with:

• Resisted wrist flexion
  
• Passive wrist extension
  
• Resisted pronation

• Medial epicondylitis

⊕ Tinel’s sign

• Cubital tunnel syndrome

• PT