clinical assessmentmri imaging. panacea ?pandora’s box ?

COMMON KNEE AND SHOULDER PROBLEMS

CLINICAL ASSESSMENT MRI IMAGING

MRI

PANACEA ? PANDORA’S BOX ?

MRI

INCEPTION 1980’S REVOLUTIONIZED EVALUATION OF STI SUPERB ST CONTRAST cf OTHER DI MULTIPLE PLANES

MRI 101

PROTONS ALIGN WITH MAGNETIC FIELD RFW DISTURB ALIGNMENT. ENERGY RELEASED DURING

REALIGNMENT MEASURED AND USED TO GENERATE IMAGE

RF SEQUENCES MANIPULATED TO HIGHLIGHT DIFFERENT TISSUES IN DIFFERENT WAYS

MRI 101 (continued)

TEMPTATION REALITY

SOPHISTICATED, ELEGANT TECHNOLOGY

ANATOMY TEXT-LIKE IMAGES

TEMPTING TO VIEW AS THE DEFINITIVE Ix

DEPENDING ON TISSUE, SENSITIVITY 80 – 95%

SPECIFICITY LESS THUS POTENTIALLY

SIGNIFICANT FALSE + AND FALSE -

MRI 101 (cont)

OTHER PROBLEMS

EXPENSIVE LONG WAITS -> CAN LEAD

TO UNNECESSARY DELAY IN RX

PATIENT INTOLERANCE PRESSURES TO ORDER

FROM PTS, PT, DC, LAWYER, ETC (might be easier to say “can’t order” than to spend time explaining why inappropriate)

TIME TO PROPERLY COMPLETE REQUISITION

ACUTE KNEE INJURIES

HISTORY:• MECHANISM OF

INJURY• SWELLING• MECHANICAL

SYMPTOMS• PAIN

MENISCAL TEAR

MECHANISM: Compression usually necessary, rotation, valgus

MEDIAL > LATERAL SWELLING: Gradual MECHANICAL SX: Clunking, locking PAIN: Not necessarily localized

MENISCAL TEAR

CLINICAL ASSESSMENT:SQUAT

MENISCAL TEAR

CLLINICAL ASSESSMENT:THESSALY TEST

MENISCAL TEAR

CLINICAL ASSESSMENT:JOINT LINE TENDERNESS

MENISCAL TEAR

CLINICAL ASSESSMENT:McMURRAY

ACUTE KNEE INJURY: ? XRAY

OTTAWA KNEE RULES

AGE > 55 ISOLATED TENDERNESS

OF PATELLA (NO OTHER BONY TENDERNESS)

TENDERNESS OF HEAD OF FIBULA

INABILITY TO FLEX KNEE TO 90 DEGREES

INABILITY TO BEAR WEIGHT IMMEDIATELY AND IN ER

(MASSIVE SWELLING)

MENISCAL TEAR: ?MRI

YES NO

EQUIVOCAL CLINICAL PRESENTATION AND NO IMPROVEMENT WITH PT

HIGH SUSPICION OF OTHER INJURY (ACL, PCL, SUBCHONDRAL)

CLASSICAL PRESENTATION

DEGENERATIVE CHANGES

MEDIAL MENISCAL TEAR

MCL SPRAIN

MECHANISM: VALGUS STRESS IF SIGNIFICANT SWELLING SUSPECT

ASSOCIATED INJURY IF SENSE OF INSTABILITY AND LITTLE PAIN

SUSPECT HIGH-GRADE INJURY

CLINICAL ASSESSMENT: VALGUS STRESS AT 30 DEGREES AND FULL EXTENSION (if gap at full extension, suspect MCL + ACL)

Gr 1: 1-5 mm, firm EF Gr 2: 6-10 mm, firm Gr 3: >10 mm, soft

MCL SPRAIN

MCL SPRAIN: ?MRI

YES NO

HIGH SUSPICION OF ACL OR PCL

ISOLATED MCL

MCL - MRI

NORMAL

MCL SPRAIN - MRI

GR 2 GR 3

ACL SPRAIN

MECHANISM: ROTATION, VALGUS, HYPEREXTENSION

SWELLING: IMMEDIATE, MASSIVE MECHANICAL SX: INSTABILITY PAIN: DIFFUSE

DO NOT MISS THIS

ACL SPRAIN

CLINICAL ASSESSMENT: LACHMAN TEST

Gr 1: 1-5mm > contralat

Gr 2: 6-10mm Gr 3: >10mm A=firm B=soft

ACL SPRAIN

CLINICAL ASSESSMENT: ANTERIOR DRAWER

ACL SPRAIN

CLINICAL ASSESSMENT: PIVOT SHIFT

Knee relaxed, full ext. Valgus stress to tibia with axial load and int rot. Knee flexed. Lat tibia subluxes, reduces with flex.

Gr 0: no detectable shift Gr 1: glide Gr 2: abrupt reduction Gr 3: temporary lock then

reduction

ACL SPRAIN

CLINICAL ASSESSMENT: PIVOT SHIFT

ACL SPRAIN: ?MRI

YES NO

HIGH LIKELIHOOD OF ASSOCIATED STI, SUBCHONDRAL INJURY, BONE BRUISING

“OLDER” PATIENT WHO IS BETTER MANAGED WITH PT, ACTIVITY MODIFICATION, BRACING

ACL TEAR

PCL SPRAIN

MECHANISM: DIRECT BLOW TO TIBIA WITH KNEE FLEXED, HYPEREXTENSION, VARUS/VALGUS STRESS IF FIRST LINE OF DEFENCE TORN

SWELLING: OVER 24 HR MECHANICAL SX: +/- INSTABILITY PAIN: DIFFUSE, POSTERIOR (RARELY SEEN AS ISOLATED INJURY)

PCL SPRAIN

CLINICAL ASSESSMENT: POSTERIOR SAG

PCL SPRAIN

CLINICAL ASSESSMENT: POSTERIOR DRAWER

PCL SPRAIN: ?MRI

YES:

HIGH LIKELIHOOD OF ASSOCIATED INJURY

PATELLAR DISLOCATION/SUBLUXATION

MECHANISM: VALGUS, ROTATION SWELLING: IMMEDIATE, MASSIVE MECHANICAL SX: NO UNLESS #

(SUBCHONDRAL #), ASSOC INJURY PAIN: DIFFUSE

PATELLAR DISLOCATION/SUBLUXATION

CLINICAL ASSESSMENT

PATELLAR TENDERNESS

MEDIAL SOFT TISSUE TENDERNESS

PATELLAR APPREHENSION TEST

PATELLA ALTA, “J” SIGN

PATELLAR DISLOCATION/SUBLUXATION

XRAY? MRI?

YES: R/O # NO, UNLESS SUSPICION OF SUBCHONDRAL #, ASSOCIATED STI

PATELLAR DISLOCATION/SUBLUXATION

ACUTE SHOULDER PROBLEMS: GLENOHUMERAL DISLOCATION

TUBS AMBRI

TUBS

MECHANISM: ABD/ER XR TO R/O # SHOULDER IMMOBILIZER FOR COMFORT;

D/C ASAP (CONSIDER ER BRACE) EARLY PT NO MRI

TUBS: RECURRENT

ANTERIOR APPREHENSION TEST/FOWLER’S RELOCATION SIGN

XR: AP, Y VIEW, AXILLARY, WEST POINT (BANKART), STRYKER NOTCH (HILL-SACHS)

REFER NO MRI

ANTERIOR APPREHENSION SIGN

FOWLER’S RELOCATION SIGN

AMBRI

GENERALIZED JOINT LAXITY LOAD AND SHIFT TEST, INFERIOR SULCUS

SIGN PT NO XR, MRI

LOAD AND SHIFT INFERIOR SULCUS

LABRAL TEAR

MECHANISM: DIRECT BLOW, DISLOCATION/SUBLUXATION, REPETITIVE OVERHEAD STRESS (MOST COMMON)

USUALLY ACCOMPANIES OTHER PATHOLOGY WHICH IS MAIN FOCUS OF RX: INSTABILITY, RC TENDINOPATHY/IMPINGEMENT

SLAP/BICEPS TENDINOPATHY

MECHANISM: FALL, LOAD IN FLEX/EXT, OVERHEAD OVERUSE

SX: PAIN, CATCHING WITH LOAD IN FLEX; CLICK; IMPINGEMENT; SENSE OF INSTABILITY

TEST

BICEPS TENDINOPATHY: SPEED’S

TESTS

SLAP: O’BRIEN’S, CRANK, PAIN PROVOCATIVE, COMPRESSION ROTATION, BICEPS LOAD

O’BRIEN’S

MRI?

LABRAL TEAR/SLAP BICEPS TENDINOPATHY

NO – NEED MRA NO – EASY CLINICAL DX, WON’T CHANGE RX, WORST CASE OUTCOME IS A COSMETIC PROBLEM

ROTATOR CUFF TENDINOPATHY, TEAR, IMPINGEMENT

MECHANISM SYMPTOMS

TRAUMA USUALLY OVERHEAD

OVERLOAD

PAIN: DIFFUSE, OFTEN SUPERIOR REFERRED TO DELTOID INSERTION

+/- CLICK IMPINGEMENT:

SEVERE PAIN WITH ELEVATION/IR

WEAKNESS: ?PAIN-INHIBITION

IMPINGEMENT EXAM: PAINFUL ARC +

HAWKINS NEERS

ROTATOR CUFF EXAM

SUPRASPINATUS: JOBE’S (EMPTY CAN)

ROTATOR CUFF EXAM

INFRASPINATUS

ROTATOR CUFF EXAM

TERES MINOR

ROTATOR CUFF EXAM

SUBSCAPULARIS: LIFTOFF (CAN ALSO DO BELLY PRESS) NO

ROTATOR CUFF: ?MRI

IF STRONG SUSPICION OF TEAR: YES

ROTATOR CUFF MRI

SS TENDINOPATHY SS TEAR