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Common Musculoskeletal Problems Wrist and Hand Pain Wrist and hand pain may be caused by trauma or overuse leading to musculoskeletal abnormalities and nerve compres- sion. A thorough history and physical examination can local- ize the source of pain and narrow the differential diagnosis; however, plain radiography is often necessary to make a defin- itive diagnosis. Acute wrist or hand pain associated with trauma sug- gests fracture or dislocation and requires radiography for evaluation, especially for scaphoid and hamate fractures. Both types of fracture frequently result from a fall onto an outstretched hand. Scaphoid fractures are characterized by pain and tenderness in the anatomic snuffbox. Initial radio- graphs are normal in up to 20% of patients. If clinical suspi- FIGURE 15. Finkelstein test for de Quervain stenosing tenosynovitis. Pain that cion is high and radiographs are normal, thumb splinting is elicited by flexing the thumb into the palm, closing the fingers over the thumb, and repeat radiography in 1 to 2 weeks or immediate MRI or and then bending the wrist in the ulnar direction is confirmatory. CT is recommended. Hamate fractures typically present with Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American pain over the hypothenar eminence, and radiographs usually College of Physicians; 2003. ©2003, American College of Physicians.

Wrist and Hand Pain Wrist and hand pain may be caused by trauma or overuse leading to musculoskeletal abnormalities and nerve compres- sion. A thorough history and physical examination can local- ize the source of pain and narrow the differential diagnosis; however, plain radiography is often necessary to make a defin- itive diagnosis. Acute wrist or hand pain associated with trauma sug- gests fracture or dislocation and requires radiography for evaluation, especially for scaphoid and hamate fractures. Both types of fracture frequently result from a fall onto an outstretched hand. Scaphoid fractures are characterized by pain and tenderness in the anatomic snuffbox. Initial radio- graphs are normal in up to 20% of patients. If clinical suspi- FIGURE 15. Finkelstein test for de Quervain stenosing tenosynovitis. Pain that cion is high and radiographs are normal, thumb splinting is elicited by flexing the thumb into the palm, closing the fingers over the thumb, and repeat radiography in 1 to 2 weeks or immediate MRI or and then bending the wrist in the ulnar direction is confirmatory. CT is recommended. Hamate fractures typically present with Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American pain over the hypothenar eminence, and radiographs usually College of Physicians; 2003. ©2003, American College of Physicians. reveal the fracture. may benefit patients with symptoms that do not respond to Ulnar neuropathy from ulnar nerve entrapment at the glucocorticoid injections. wrist is characterized by wrist pain, interosseous muscle Osteoarthritis and inflammatory arthritis may affect the weakness, and diminished sensation in the fourth and interphalangeal and carpometacarpal joints and cause hand fifth digits. Patients with symptoms that persist for and wrist pain (see MKSAP 19 Rheumatology). longer than 6 months should be considered for surgical intervention. Carpal Tunnel Syndrome Ganglion cysts are caused by herniated synovial tissue Carpal tunnel syndrome develops from increased pressure surrounding tendon sheaths (Figure 14). Painful cysts may be within the carpal tunnel causing median nerve compression. aspirated; if cysts recur after aspiration, surgical resection is The syndrome is characterized by volar wrist pain that may effective. radiate to the forearm and hand; paresthesia and weakness of De Quervain tendinopathy results from noninflammatory the first three fingers and thenar eminence (median nerve thickening of the thumb tendons. Pain occurs at the thumb distribution) may be present. Symptoms are often worse at base, radiates to the distal radius, and is elicited with making night and with repetitive wrist motion. a fist over the thumb and ulnar deviation of the wrist Examination findings may include hypoalgesia or (Finkelstein test) (Figure 15). Initial management includes rest, decreased sensation over the median nerve distribution, thenar NSAIDs, and splinting. When conservative measures fail, glu- muscle atrophy, and weakened thumb abduction. Examination cocorticoid injections provide symptomatic relief. Surgery is often normal early in the disease, and provocative testing with the Phalen maneuver (flexion of hands at wrists) or Tinel test (percussion of the median nerve on top of the carpal tun- nel) is rarely useful. Electrodiagnostic testing is beneficial when the diagnosis is unclear, especially when cervical radic- ulopathy is possible. Initial treatment includes activity modification and wrist splinting. Glucocorticoid injection or a short course of oral glucocorticoids may provide symptomatic improvement in more than half of patients. Surgical division of the transverse carpal ligament promptly relieves dysesthesia and should be considered in severe or recalcitrant disease.

reveal the fracture. may benefit patients with symptoms that do not respond to Ulnar neuropathy from ulnar nerve entrapment at the glucocorticoid injections. wrist is characterized by wrist pain, interosseous muscle Osteoarthritis and inflammatory arthritis may affect the weakness, and diminished sensation in the fourth and interphalangeal and carpometacarpal joints and cause hand fifth digits. Patients with symptoms that persist for and wrist pain (see MKSAP 19 Rheumatology). longer than 6 months should be considered for surgical intervention. Carpal Tunnel Syndrome Ganglion cysts are caused by herniated synovial tissue Carpal tunnel syndrome develops from increased pressure surrounding tendon sheaths (Figure 14). Painful cysts may be within the carpal tunnel causing median nerve compression. aspirated; if cysts recur after aspiration, surgical resection is The syndrome is characterized by volar wrist pain that may effective. radiate to the forearm and hand; paresthesia and weakness of De Quervain tendinopathy results from noninflammatory the first three fingers and thenar eminence (median nerve thickening of the thumb tendons. Pain occurs at the thumb distribution) may be present. Symptoms are often worse at base, radiates to the distal radius, and is elicited with making night and with repetitive wrist motion. a fist over the thumb and ulnar deviation of the wrist Examination findings may include hypoalgesia or (Finkelstein test) (Figure 15). Initial management includes rest, decreased sensation over the median nerve distribution, thenar NSAIDs, and splinting. When conservative measures fail, glu- muscle atrophy, and weakened thumb abduction. Examination cocorticoid injections provide symptomatic relief. Surgery is often normal early in the disease, and provocative testing with the Phalen maneuver (flexion of hands at wrists) or Tinel test (percussion of the median nerve on top of the carpal tun- nel) is rarely useful. Electrodiagnostic testing is beneficial when the diagnosis is unclear, especially when cervical radic- ulopathy is possible. Initial treatment includes activity modification and wrist splinting. Glucocorticoid injection or a short course of oral glucocorticoids may provide symptomatic improvement in more than half of patients. Surgical division of the transverse carpal ligament promptly relieves dysesthesia and should be considered in severe or recalcitrant disease. ¢ Initial treatment of carpal tunnel syndrome includes HVC activity modification and wrist splinting; glucocorticoid FIGURE 14. Aganglion, which is a cystic swelling overlying a joint or tendon injection or a short course of oral glucocorticoids may sheath. provide symptomatic improvement in more than half of Reproduced with permission from Moore G. Atlas of the Musculoskeletal E Philadelphia, PA: American patients. College of Physicians; 2003. ©2003, American College of Physicians.

¢ Initial treatment of carpal tunnel syndrome includes HVC activity modification and wrist splinting; glucocorticoid FIGURE 14. Aganglion, which is a cystic swelling overlying a joint or tendon injection or a short course of oral glucocorticoids may sheath. provide symptomatic improvement in more than half of Reproduced with permission from Moore G. Atlas of the Musculoskeletal E Philadelphia, PA: American patients. College of Physicians; 2003. ©2003, American College of Physicians. 59

Common Musculoskeletal Problems Lower Extremity Disorders TABLE 37. Features and Likelihood of Hip Osteoarthritis Hip Pain | Features Supporting Hip Positive LR Osteoarthritis Diagnosis and Evaluation The evaluation of hip pain can be challenging owing to the Family history of osteoarthritis |

Hip Pain | Features Supporting Hip Positive LR Osteoarthritis Diagnosis and Evaluation The evaluation of hip pain can be challenging owing to the Family history of osteoarthritis | complexity of the joint and multifactorial nature of up to 25% History of knee osteoarthritis 2.1 of cases. The location of the pain (anterior/groin, lateral, or Medial thigh/groin pain 78 posterior) is often helpful in focusing the evaluation. Intra- Pain climbing stairs or walking 2.1 articular hip pain can be difficult to localize, and patients may down slopes try to indicate an internal region by cupping the lateral hip Abductor weakness 45 with their hand (“C sign”) (Figure 16). Squat causing posterior pain 6.1 Anterior hip pain can be caused by both intra- and extra- Groin pain on abduction or Sy) articular conditions. In older patients, pain that starts insidi- adduction ously and worsens with standing and activity suggests Decreased hip adduction 4.2 osteoarthritis (Table 37). The same pain characteristics in a Decreased hip internal rotation 32 younger person raise concern for a labral tear if accompanied by painful clicking or catching, or femoroacetabular impinge- Inguinal ligament tenderness 2.4 | ment ifit is associated with pain at the extremes of movement. Features Supporting an Negative LR Femoroacetabular impingement is attributed to abnormal | Alternative Diagnosis contact of the femoral head-neck junction against the acetab- | Age <50 y; age <60y 0.32; 0.11 ular rim of the hip joint with normal range of motion. Absence of pain with walking 0.25-0.58 Femoroacetabular impingement produces insidious groin pain Morning stiffness >60 min 0.22-0.65 that is worse after sitting for a prolonged period and improves with standing. Gradual onset of anterior hip pain can also Pain aggravated with sitting 0.24

complexity of the joint and multifactorial nature of up to 25% History of knee osteoarthritis 2.1 of cases. The location of the pain (anterior/groin, lateral, or Medial thigh/groin pain 78 posterior) is often helpful in focusing the evaluation. Intra- Pain climbing stairs or walking 2.1 articular hip pain can be difficult to localize, and patients may down slopes try to indicate an internal region by cupping the lateral hip Abductor weakness 45 with their hand (“C sign”) (Figure 16). Squat causing posterior pain 6.1 Anterior hip pain can be caused by both intra- and extra- Groin pain on abduction or Sy) articular conditions. In older patients, pain that starts insidi- adduction ously and worsens with standing and activity suggests Decreased hip adduction 4.2 osteoarthritis (Table 37). The same pain characteristics in a Decreased hip internal rotation 32 younger person raise concern for a labral tear if accompanied by painful clicking or catching, or femoroacetabular impinge- Inguinal ligament tenderness 2.4 | ment ifit is associated with pain at the extremes of movement. Features Supporting an Negative LR Femoroacetabular impingement is attributed to abnormal | Alternative Diagnosis contact of the femoral head-neck junction against the acetab- | Age <50 y; age <60y 0.32; 0.11 ular rim of the hip joint with normal range of motion. Absence of pain with walking 0.25-0.58 Femoroacetabular impingement produces insidious groin pain Morning stiffness >60 min 0.22-0.65 that is worse after sitting for a prolonged period and improves with standing. Gradual onset of anterior hip pain can also Pain aggravated with sitting 0.24 occur with avascular necrosis (osteonecrosis), which should Absence of pain with adduction —_(0.43-0.59

complexity of the joint and multifactorial nature of up to 25% History of knee osteoarthritis 2.1 of cases. The location of the pain (anterior/groin, lateral, or Medial thigh/groin pain 78 posterior) is often helpful in focusing the evaluation. Intra- Pain climbing stairs or walking 2.1 articular hip pain can be difficult to localize, and patients may down slopes try to indicate an internal region by cupping the lateral hip Abductor weakness 45 with their hand (“C sign”) (Figure 16). Squat causing posterior pain 6.1 Anterior hip pain can be caused by both intra- and extra- Groin pain on abduction or Sy) articular conditions. In older patients, pain that starts insidi- adduction ously and worsens with standing and activity suggests Decreased hip adduction 4.2 osteoarthritis (Table 37). The same pain characteristics in a Decreased hip internal rotation 32 younger person raise concern for a labral tear if accompanied by painful clicking or catching, or femoroacetabular impinge- Inguinal ligament tenderness 2.4 | ment ifit is associated with pain at the extremes of movement. Features Supporting an Negative LR Femoroacetabular impingement is attributed to abnormal | Alternative Diagnosis contact of the femoral head-neck junction against the acetab- | Age <50 y; age <60y 0.32; 0.11 ular rim of the hip joint with normal range of motion. Absence of pain with walking 0.25-0.58 Femoroacetabular impingement produces insidious groin pain Morning stiffness >60 min 0.22-0.65 that is worse after sitting for a prolonged period and improves with standing. Gradual onset of anterior hip pain can also Pain aggravated with sitting 0.24 occur with avascular necrosis (osteonecrosis), which should Absence of pain with adduction —_(0.43-0.59 Absence of pain with internal 0.31-0.45 rotation

complexity of the joint and multifactorial nature of up to 25% History of knee osteoarthritis 2.1 of cases. The location of the pain (anterior/groin, lateral, or Medial thigh/groin pain 78 posterior) is often helpful in focusing the evaluation. Intra- Pain climbing stairs or walking 2.1 articular hip pain can be difficult to localize, and patients may down slopes try to indicate an internal region by cupping the lateral hip Abductor weakness 45 with their hand (“C sign”) (Figure 16). Squat causing posterior pain 6.1 Anterior hip pain can be caused by both intra- and extra- Groin pain on abduction or Sy) articular conditions. In older patients, pain that starts insidi- adduction ously and worsens with standing and activity suggests Decreased hip adduction 4.2 osteoarthritis (Table 37). The same pain characteristics in a Decreased hip internal rotation 32 younger person raise concern for a labral tear if accompanied by painful clicking or catching, or femoroacetabular impinge- Inguinal ligament tenderness 2.4 | ment ifit is associated with pain at the extremes of movement. Features Supporting an Negative LR Femoroacetabular impingement is attributed to abnormal | Alternative Diagnosis contact of the femoral head-neck junction against the acetab- | Age <50 y; age <60y 0.32; 0.11 ular rim of the hip joint with normal range of motion. Absence of pain with walking 0.25-0.58 Femoroacetabular impingement produces insidious groin pain Morning stiffness >60 min 0.22-0.65 that is worse after sitting for a prolonged period and improves with standing. Gradual onset of anterior hip pain can also Pain aggravated with sitting 0.24 occur with avascular necrosis (osteonecrosis), which should Absence of pain with adduction —_(0.43-0.59 Absence of pain with internal 0.31-0.45 rotation Normal hip range of motion 0.25-0.26 (unrestricted abduction/adduction); 0.37-0.43 (unrestricted internal/external rotation)

Normal hip range of motion 0.25-0.26 (unrestricted abduction/adduction); 0.37-0.43 (unrestricted internal/external rotation) | Absence of limp 0:35 LR = likelihood ratio. Data from Metcalfe D, Perry DC, Claireaux HA, et al. Does this patient have hip osteoarthritis?: the rational clinical examination systematic review. JAMA. | 2019;3 [PMID: 31846019] 22:232 doi:10.1001/jama.2019 3-33. .19413 be considered in the presence of alcohol use disorder, gluco- corticoid use, systemic lupus erythematosus, or sickle cell

Data from Metcalfe D, Perry DC, Claireaux HA, et al. Does this patient have hip osteoarthritis?: the rational clinical examination systematic review. JAMA. | 2019;3 [PMID: 31846019] 22:232 doi:10.1001/jama.2019 3-33. .19413 be considered in the presence of alcohol use disorder, gluco- corticoid use, systemic lupus erythematosus, or sickle cell anemia. Acute-onset, anteriorly located hip pain that interferes with weight bearing and is accompanied by fever raises suspi- cion for infectious arthritis, whereas acute pain after a fall suggests fracture. Anterior hip pain presenting in athletes has a unique differential diagnosis; the most common causes are femoroacetabular impingement, sports hernia (athletic pubal- gia), adductor strain or tear, inguinal hernia, and labral tear. Patients with anterior hip pain should be assessed for intra- abdominal processes (e.g., nephrolithiasis, inguinal hernia, ovarian pathology, or appendicitis) because these can refer pain to the groin or anterior hip. Lateral hip pain is most commonly caused by greater tro- chanteric pain syndrome (GTPS) (formerly known as trochan-

anemia. Acute-onset, anteriorly located hip pain that interferes with weight bearing and is accompanied by fever raises suspi- cion for infectious arthritis, whereas acute pain after a fall suggests fracture. Anterior hip pain presenting in athletes has a unique differential diagnosis; the most common causes are femoroacetabular impingement, sports hernia (athletic pubal- gia), adductor strain or tear, inguinal hernia, and labral tear. Patients with anterior hip pain should be assessed for intra- abdominal processes (e.g., nephrolithiasis, inguinal hernia, ovarian pathology, or appendicitis) because these can refer pain to the groin or anterior hip. Lateral hip pain is most commonly caused by greater tro- chanteric pain syndrome (GTPS) (formerly known as trochan- FIGURE 16. The "C sign." Intra-articular hip pain can be difficult to localize, teric bursitis) or meralgia paresthetica. Pain that worsens with and patients may try to indicate an internal region by cupping the lateral hip with lying on the affected side suggests GTPS; the pain may also their hand. radiate to the buttock or knee if the iliotibial band is also 60

Common Musculoskeletal Problems affected. Meralgia paresthetica is characterized by distal antero- with groin pain suggests an extra-articular cause, such as an lateral thigh paresthesia associated with tight-fitting clothes or inguinal hernia. Reproduction of the pain during the straight obesity. Symptoms follow the distribution of the lateral femoral leg raise test (see Figure 10) supports lumbar radiculopathy. cutaneous nerve, and sensory deficits may be present. Radiographs (anteroposterior pelvic view and frog-leg

affected. Meralgia paresthetica is characterized by distal antero- with groin pain suggests an extra-articular cause, such as an lateral thigh paresthesia associated with tight-fitting clothes or inguinal hernia. Reproduction of the pain during the straight obesity. Symptoms follow the distribution of the lateral femoral leg raise test (see Figure 10) supports lumbar radiculopathy. cutaneous nerve, and sensory deficits may be present. Radiographs (anteroposterior pelvic view and frog-leg CO i CC) UT TAT ulopathy, vascular claudication, sacroiliac joint dysfunction, or fracture, or dislocation is suspected. In patients with persistent gluteal tendinopathy. Pain associated with radiation down the anterior pain and normal radiographs, MRI of the hip can be leg suggests lumbar radiculopathy, whereas concomitant exer- performed; however, if suspicion is high for a labral tear, MR tional leg pain or peripheral vascular disease suggests vascular arthrography should be performed. Hip aspiration is indicated claudication. Lumbar radiculopathy can also present as ante- if infectious arthritis is suspected. rior or lateral hip pain depending on the nerve root involved. Back pain may be present, particularly if an intervertebral disk Treatment has extruded. Osteoarthritis of the hip can present with pain Initial management of labral tears includes muscle strengthen- that refers to the buttocks but is associated with other features ing and activity modification, with arthroscopic surgery typical of intra-articular pathology. Isolated posterior pain reserved for those in whom conservative measures fail. Patients may be secondary to sacroiliac joint dysfunction, although the with advanced avascular necrosis often require total hip arthro- presence of morning stiffness, fever, or peripheral joint symp- plasty. Femoroacetabular impingement is initially treated with toms should prompt consideration of sacroiliitis. physical therapy, although surgery may be required in some Examination of patients with hip pain includes evaluation cases. Gluteal tendinopathy is treated with rest and physical of the hip, abdomen, and back; neurologic and vascular assess- therapy. ments of the legs; and gait assessment. Pain with both passive Initial management of GTPS includes activity modifica- and active hip movement suggests an intra-articular cause, as tion and analgesia with acetaminophen or NSAIDs. does pain or restricted range of motion with internal rotation Glucocorticoid injection or extracorporeal shockwave treat- or the FADIR (Flexion, ADduction, and Internal Rotation) test. ment can be considered for persistently symptomatic GTPS, The FABER (Flexion, ABduction, and External Rotation) test with surgery limited to recalcitrant cases. Primary treatment may cause posterior hip pain in the presence of sacroiliac joint of meralgia paresthetica consists of reassurance, avoidance of dysfunction, groin pain with an intra-articular cause, and lat- tight-fitting clothes, and weight loss. First-line therapy for eral hip pain with GTPS (Figure 17). The most common exami- sacroiliac joint dysfunction is physical therapy; limited evi- nation finding in GTPS, however, is tenderness to palpation of dence supports local glucocorticoid injection. the greater trochanter. A normal hip examination in a patient Management of osteoarthritis is discussed in MKSAP 19 Rheumatology.

CO i CC) UT TAT ulopathy, vascular claudication, sacroiliac joint dysfunction, or fracture, or dislocation is suspected. In patients with persistent gluteal tendinopathy. Pain associated with radiation down the anterior pain and normal radiographs, MRI of the hip can be leg suggests lumbar radiculopathy, whereas concomitant exer- performed; however, if suspicion is high for a labral tear, MR tional leg pain or peripheral vascular disease suggests vascular arthrography should be performed. Hip aspiration is indicated claudication. Lumbar radiculopathy can also present as ante- if infectious arthritis is suspected. rior or lateral hip pain depending on the nerve root involved. Back pain may be present, particularly if an intervertebral disk Treatment has extruded. Osteoarthritis of the hip can present with pain Initial management of labral tears includes muscle strengthen- that refers to the buttocks but is associated with other features ing and activity modification, with arthroscopic surgery typical of intra-articular pathology. Isolated posterior pain reserved for those in whom conservative measures fail. Patients may be secondary to sacroiliac joint dysfunction, although the with advanced avascular necrosis often require total hip arthro- presence of morning stiffness, fever, or peripheral joint symp- plasty. Femoroacetabular impingement is initially treated with toms should prompt consideration of sacroiliitis. physical therapy, although surgery may be required in some Examination of patients with hip pain includes evaluation cases. Gluteal tendinopathy is treated with rest and physical of the hip, abdomen, and back; neurologic and vascular assess- therapy. ments of the legs; and gait assessment. Pain with both passive Initial management of GTPS includes activity modifica- and active hip movement suggests an intra-articular cause, as tion and analgesia with acetaminophen or NSAIDs. does pain or restricted range of motion with internal rotation Glucocorticoid injection or extracorporeal shockwave treat- or the FADIR (Flexion, ADduction, and Internal Rotation) test. ment can be considered for persistently symptomatic GTPS, The FABER (Flexion, ABduction, and External Rotation) test with surgery limited to recalcitrant cases. Primary treatment may cause posterior hip pain in the presence of sacroiliac joint of meralgia paresthetica consists of reassurance, avoidance of dysfunction, groin pain with an intra-articular cause, and lat- tight-fitting clothes, and weight loss. First-line therapy for eral hip pain with GTPS (Figure 17). The most common exami- sacroiliac joint dysfunction is physical therapy; limited evi- nation finding in GTPS, however, is tenderness to palpation of dence supports local glucocorticoid injection. the greater trochanter. A normal hip examination in a patient Management of osteoarthritis is discussed in MKSAP 19 Rheumatology. e In patients with intra-articular causes of hip pain, pain or restricted range of motion are present with internal rotation or the FADIR (Flexion, ADduction, and Internal

e In patients with intra-articular causes of hip pain, pain or restricted range of motion are present with internal rotation or the FADIR (Flexion, ADduction, and Internal Rotation) test. ¢ The FABER (Flexion, ABduction, and External Rotation) test may cause posterior hip pain in the presence of sacro- iliac joint dysfunction, groin pain with an intra-articular cause, and lateral hip pain with greater trochanteric pain syndrome. ¢ Hip radiography should be performed if an intra-articular pathology, fracture, or dislocation is suspected.

Rotation) test. ¢ The FABER (Flexion, ABduction, and External Rotation) test may cause posterior hip pain in the presence of sacro- iliac joint dysfunction, groin pain with an intra-articular cause, and lateral hip pain with greater trochanteric pain syndrome. ¢ Hip radiography should be performed if an intra-articular pathology, fracture, or dislocation is suspected. Knee and Leg Pain FIGURE 17. The FABER (Flexion, ABduction, and External Rotation) test. With the patient supine, the leg on the tested side is placed in the “figure 4" position Diagnosis and Evaluation (the knee of the tested side is flexed 90 degrees, and the lateral malleolus is In patients with knee pain, the history should focus on timing placed on top of the opposite leg). The examiner then applies a posteriorly directed (acute, subacute, or chronic) and pain characteristics. History force with one hand while using the other hand to stabilize the patient's other hip. of knee injury or surgery, osteoarthritis, and crystal arthropa- The result is positive if groin pain or buttock pain is produced. Buttock pain thies should also be elicited. suggests sacroiliac joint dysfunction, and groin pain suggests an intra-articular cause. Knee examination, performed with both knees fully exposed, includes inspection, palpation, range of motion test- Reproduced with permission from Davis MF, Davis PF, Ross DS. Expert Guide to Sports Medicine. Philadelphia, PA: American College of Physicians, 2005:360. ©2005, American College of Physicians. ing, and special maneuvers (Table 38).

Knee and Leg Pain FIGURE 17. The FABER (Flexion, ABduction, and External Rotation) test. With the patient supine, the leg on the tested side is placed in the “figure 4" position Diagnosis and Evaluation (the knee of the tested side is flexed 90 degrees, and the lateral malleolus is In patients with knee pain, the history should focus on timing placed on top of the opposite leg). The examiner then applies a posteriorly directed (acute, subacute, or chronic) and pain characteristics. History force with one hand while using the other hand to stabilize the patient's other hip. of knee injury or surgery, osteoarthritis, and crystal arthropa- The result is positive if groin pain or buttock pain is produced. Buttock pain thies should also be elicited. suggests sacroiliac joint dysfunction, and groin pain suggests an intra-articular cause. Knee examination, performed with both knees fully exposed, includes inspection, palpation, range of motion test- Reproduced with permission from Davis MF, Davis PF, Ross DS. Expert Guide to Sports Medicine. Philadelphia, PA: American College of Physicians, 2005:360. ©2005, American College of Physicians. ing, and special maneuvers (Table 38). 61

Common Musculoskeletal Problems TABLE 38. Knee Examination Maneuvers | Maneuver Purpose Description Likelihood Ratio? | Anterior ACL integrity The patient is supine with the hip flexed to 45 degrees and knee flexed to Positive likelihood drawer 90 degrees. The examiner sits on the dorsum of the foot and places his or ratio: 3.84 her hands on the proximal calf and then pulls anteriorly while assessing Negative likelihood movement of tibia relative to femur. ratio: 0.30? Positive result: Increased laxity with lack of a firm end point suggests an ACL tear.

| Anterior ACL integrity The patient is supine with the hip flexed to 45 degrees and knee flexed to Positive likelihood drawer 90 degrees. The examiner sits on the dorsum of the foot and places his or ratio: 3.84 her hands on the proximal calf and then pulls anteriorly while assessing Negative likelihood movement of tibia relative to femur. ratio: 0.30? Positive result: Increased laxity with lack of a firm end point suggests an ACL tear. | Lachman ACL integrity The patient is supine with the leg in slight external rotation and the knee Positive likelihood flexed 20-30 degrees at the examiner's side. The examiner stabilizes the ratio: 42.05 femur with one hand and grasps the proximal calf with the other. He or she Negative likelihood pulls the calf while assessing movement of the tibia relative to the femur. ratio: 0.15 Positive result: Increased laxity with lack of a firm end point suggests an ACL tear.

| Lachman ACL integrity The patient is supine with the leg in slight external rotation and the knee Positive likelihood flexed 20-30 degrees at the examiner's side. The examiner stabilizes the ratio: 42.05 femur with one hand and grasps the proximal calf with the other. He or she Negative likelihood pulls the calf while assessing movement of the tibia relative to the femur. ratio: 0.15 Positive result: Increased laxity with lack of a firm end point suggests an ACL tear. Posterior PCL integrity The patient is supine with the hip flexed to 45 degrees and the knee flexed to Positive likelihood drawer 90 degrees. The examiner sits on the dorsum ofthe foot and places his or her ratio: 50.11° hands on the proximal calf and then pushes posteriorly while assessing Negative likelihood movement of tibia relative to femur. ratio: 0.11° Positive result: Increased laxity with lack of a firm end point suggests a PCL | Valgus stress = MCL tear.

Posterior PCL integrity The patient is supine with the hip flexed to 45 degrees and the knee flexed to Positive likelihood drawer 90 degrees. The examiner sits on the dorsum ofthe foot and places his or her ratio: 50.11° hands on the proximal calf and then pushes posteriorly while assessing Negative likelihood movement of tibia relative to femur. ratio: 0.11° Positive result: Increased laxity with lack of a firm end point suggests a PCL | Valgus stress = MCL tear. The patient is supine with the knee flexed to 30 degrees and the leg slightly Positive likelihood | integrity abducted. The examiner places one hand on the lateral knee and the other ratio: 7.74 hand on the medial distal tibia and applies valgus force. Negative likelihood Positive result: Increased laxity and pain suggest an MCL tear. ratio: 0.24 Varus stress LCLintegrity The patient is supine with the knee flexed to 30 degrees and the leg slightly Positive likelihood abducted. The examiner places one hand on the medial knee and the other ratio: 16.29 hand on the lateral distal tibia and applies varus force.

Varus stress LCLintegrity The patient is supine with the knee flexed to 30 degrees and the leg slightly Positive likelihood abducted. The examiner places one hand on the medial knee and the other ratio: 16.29 hand on the lateral distal tibia and applies varus force. Positive result: Increased laxity and pain suggest an LCL tear. | Thessaly Meniscal The examiner holds the patient's outstretched hands while the patient stands Positive likelihood integrity on one leg with the knee flexed to 5 degrees and the other knee flexed to ratio: 1.37° 90 degrees with the foot off the floor. The patient rotates his or her body Negative likelihood internally and externally three times. Repeat with the knee flexed to ratio: 0.68° 20 degrees. Always perform on the uninvolved knee first. Positive result: Medial or lateral joint line pain suggests a meniscal tear.

| Thessaly Meniscal The examiner holds the patient's outstretched hands while the patient stands Positive likelihood integrity on one leg with the knee flexed to 5 degrees and the other knee flexed to ratio: 1.37° 90 degrees with the foot off the floor. The patient rotates his or her body Negative likelihood internally and externally three times. Repeat with the knee flexed to ratio: 0.68° 20 degrees. Always perform on the uninvolved knee first. Positive result: Medial or lateral joint line pain suggests a meniscal tear. Medial- Meniscal With the patient supine, the examiner places the calf in one hand and the Positive likelihood lateral grind integrity thumb and index finger of the opposite hand over joint line and applies ratio: 4.8 varus and valgus stress to the tibia during extension and flexion. Negative likelihood Positive result: A grinding sensation that is palpable over the joint line ratio: 0.46 suggests meniscal injury.

Medial- Meniscal With the patient supine, the examiner places the calf in one hand and the Positive likelihood lateral grind integrity thumb and index finger of the opposite hand over joint line and applies ratio: 4.8 varus and valgus stress to the tibia during extension and flexion. Negative likelihood Positive result: A grinding sensation that is palpable over the joint line ratio: 0.46 suggests meniscal injury. McMurray Meniscal With the patient supine, the examiner fully flexes the knee and rotates the tibia Positive likelihood integrity externally. The knee is then extended with the hand over the medial joint line. ratio: 1.3° The maneuver is then repeated with the tibia internally rotated and the hand Negative likelihood over the lateral joint line. ratio: 0.85 Positive result: Snapping is detected over the joint line with extension on the knee.

McMurray Meniscal With the patient supine, the examiner fully flexes the knee and rotates the tibia Positive likelihood integrity externally. The knee is then extended with the hand over the medial joint line. ratio: 1.3° The maneuver is then repeated with the tibia internally rotated and the hand Negative likelihood over the lateral joint line. ratio: 0.85 Positive result: Snapping is detected over the joint line with extension on the knee. Noble lliotibial With the patient supine, the examiner repeatedly flexes and extends the | band knee with examiner's thumb placed on the lateral femoral epicondyle. integrity Positive result: lliotibial band syndrome is suggested if this maneuver reproduces the patient's pain. ACL= anterior cruciate ligament; LCL = lateral collateral ligament; MCL = medial collateral ligament; PCL = posterior cruciate ligament. ®Data used to derive these values are of limited quality. | ’Data from Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical | examination. JAMA. 2001;286:1610-20. [PMID: 11585485] doi:10.1001/jama.286.13.1610 \ | “Data from Rubinstein RA Jr, Shelbourne KD, McCarroll JR, et al. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med. 1994;22:550-7. [PMID: 7943523] doi:10.1177/036354659402200419 ‘Data from McGee SR. Evidence-Based Physical Diagnosis. 4th ed. Philadelphia, PA: Elsevier; 2018.

| ’Data from Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical | examination. JAMA. 2001;286:1610-20. [PMID: 11585485] doi:10.1001/jama.286.13.1610 \ | “Data from Rubinstein RA Jr, Shelbourne KD, McCarroll JR, et al. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med. 1994;22:550-7. [PMID: 7943523] doi:10.1177/036354659402200419 ‘Data from McGee SR. Evidence-Based Physical Diagnosis. 4th ed. Philadelphia, PA: Elsevier; 2018. | ®Data from Goossens P, Keijsers E, van Geenen RJ, et al. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. J Orthop Sports Phys Ther. 2015;45:18-24, B1. [PMID: 25420009] doi:10.2519/jospt.2015.5215 62

Common Musculoskeletal Problems Radiography should be performed if fracture, bony Patellofemoral Pain Syndrome pathology, or osteoarthritis is suspected. MRI can be per- Patellofemoral pain syndrome is caused by disordered patellar formed if internal derangements are suspected and surgery is tracking with knee movement. It is characterized by poorly being considered. Joint aspiration should be performed for a localized anterior knee pain and/or stiffness with prolonged palpable effusion to exclude inflammatory or infectious sitting, climbing, or descending stairs, and with running or arthritis. squatting. On examination, applying pressure to the patella Knee osteoarthritis is discussed in MKSAP 19 Rheuma- may reproduce pain. Patellar mobility can be assessed by tology. medially and laterally displacing the patella, and abrupt patel- lar deviation may be noted during squatting and standing. The Ligament and Meniscal Tears utility of these findings is unclear. Acute, traumatic onset of knee pain, especially when associ- NSAIDs may help alleviate symptoms in the acute setting ated with swelling, should raise concern for ligamentous and/ but have not shown benefit in the long term. In the acute or meniscal tears. Anterior cruciate ligament tears usually phase of injury, modification of activity and cryotherapy (ice, involve noncontact twisting injuries. Patients may report a cold water immersion) is recommended. In the recovery popping sound and often cannot bear weight immediately. phase, the most effective treatment for patellofemoral pain Large effusions due to hemarthrosis often develop within syndrome is physical therapy with an exercise program 2 hours and may make initial examination challenging. The designed to strengthen the quadriceps muscles, hamstrings, anterior drawer and Lachman tests frequently demonstrate and gluteus muscles. Core strengthening exercises may also increased ligamentous laxity, although the Lachman test may have benefit. These strengthening exercises should be contin- be most useful in the acute setting (see Table 38). The pivot ued after pain relief. shift test can be used to assess joint stability. Radiography should be performed to evaluate for possible accompanying tibial avulsion fractures, although MRI is often obtained as e Patients with acute anterior cruciate ligament tears

Radiography should be performed if fracture, bony Patellofemoral Pain Syndrome pathology, or osteoarthritis is suspected. MRI can be per- Patellofemoral pain syndrome is caused by disordered patellar formed if internal derangements are suspected and surgery is tracking with knee movement. It is characterized by poorly being considered. Joint aspiration should be performed for a localized anterior knee pain and/or stiffness with prolonged palpable effusion to exclude inflammatory or infectious sitting, climbing, or descending stairs, and with running or arthritis. squatting. On examination, applying pressure to the patella Knee osteoarthritis is discussed in MKSAP 19 Rheuma- may reproduce pain. Patellar mobility can be assessed by tology. medially and laterally displacing the patella, and abrupt patel- lar deviation may be noted during squatting and standing. The Ligament and Meniscal Tears utility of these findings is unclear. Acute, traumatic onset of knee pain, especially when associ- NSAIDs may help alleviate symptoms in the acute setting ated with swelling, should raise concern for ligamentous and/ but have not shown benefit in the long term. In the acute or meniscal tears. Anterior cruciate ligament tears usually phase of injury, modification of activity and cryotherapy (ice, involve noncontact twisting injuries. Patients may report a cold water immersion) is recommended. In the recovery popping sound and often cannot bear weight immediately. phase, the most effective treatment for patellofemoral pain Large effusions due to hemarthrosis often develop within syndrome is physical therapy with an exercise program 2 hours and may make initial examination challenging. The designed to strengthen the quadriceps muscles, hamstrings, anterior drawer and Lachman tests frequently demonstrate and gluteus muscles. Core strengthening exercises may also increased ligamentous laxity, although the Lachman test may have benefit. These strengthening exercises should be contin- be most useful in the acute setting (see Table 38). The pivot ued after pain relief. shift test can be used to assess joint stability. Radiography should be performed to evaluate for possible accompanying tibial avulsion fractures, although MRI is often obtained as e Patients with acute anterior cruciate ligament tears well. Anterior cruciate ligament tears frequently require sur- often cannot bear weight immediately and develop

Radiography should be performed if fracture, bony Patellofemoral Pain Syndrome pathology, or osteoarthritis is suspected. MRI can be per- Patellofemoral pain syndrome is caused by disordered patellar formed if internal derangements are suspected and surgery is tracking with knee movement. It is characterized by poorly being considered. Joint aspiration should be performed for a localized anterior knee pain and/or stiffness with prolonged palpable effusion to exclude inflammatory or infectious sitting, climbing, or descending stairs, and with running or arthritis. squatting. On examination, applying pressure to the patella Knee osteoarthritis is discussed in MKSAP 19 Rheuma- may reproduce pain. Patellar mobility can be assessed by tology. medially and laterally displacing the patella, and abrupt patel- lar deviation may be noted during squatting and standing. The Ligament and Meniscal Tears utility of these findings is unclear. Acute, traumatic onset of knee pain, especially when associ- NSAIDs may help alleviate symptoms in the acute setting ated with swelling, should raise concern for ligamentous and/ but have not shown benefit in the long term. In the acute or meniscal tears. Anterior cruciate ligament tears usually phase of injury, modification of activity and cryotherapy (ice, involve noncontact twisting injuries. Patients may report a cold water immersion) is recommended. In the recovery popping sound and often cannot bear weight immediately. phase, the most effective treatment for patellofemoral pain Large effusions due to hemarthrosis often develop within syndrome is physical therapy with an exercise program 2 hours and may make initial examination challenging. The designed to strengthen the quadriceps muscles, hamstrings, anterior drawer and Lachman tests frequently demonstrate and gluteus muscles. Core strengthening exercises may also increased ligamentous laxity, although the Lachman test may have benefit. These strengthening exercises should be contin- be most useful in the acute setting (see Table 38). The pivot ued after pain relief. shift test can be used to assess joint stability. Radiography should be performed to evaluate for possible accompanying tibial avulsion fractures, although MRI is often obtained as e Patients with acute anterior cruciate ligament tears well. Anterior cruciate ligament tears frequently require sur- often cannot bear weight immediately and develop gical reconstruction, especially in active patients or those large effusions within 2 to 3 hours.

Radiography should be performed if fracture, bony Patellofemoral Pain Syndrome pathology, or osteoarthritis is suspected. MRI can be per- Patellofemoral pain syndrome is caused by disordered patellar formed if internal derangements are suspected and surgery is tracking with knee movement. It is characterized by poorly being considered. Joint aspiration should be performed for a localized anterior knee pain and/or stiffness with prolonged palpable effusion to exclude inflammatory or infectious sitting, climbing, or descending stairs, and with running or arthritis. squatting. On examination, applying pressure to the patella Knee osteoarthritis is discussed in MKSAP 19 Rheuma- may reproduce pain. Patellar mobility can be assessed by tology. medially and laterally displacing the patella, and abrupt patel- lar deviation may be noted during squatting and standing. The Ligament and Meniscal Tears utility of these findings is unclear. Acute, traumatic onset of knee pain, especially when associ- NSAIDs may help alleviate symptoms in the acute setting ated with swelling, should raise concern for ligamentous and/ but have not shown benefit in the long term. In the acute or meniscal tears. Anterior cruciate ligament tears usually phase of injury, modification of activity and cryotherapy (ice, involve noncontact twisting injuries. Patients may report a cold water immersion) is recommended. In the recovery popping sound and often cannot bear weight immediately. phase, the most effective treatment for patellofemoral pain Large effusions due to hemarthrosis often develop within syndrome is physical therapy with an exercise program 2 hours and may make initial examination challenging. The designed to strengthen the quadriceps muscles, hamstrings, anterior drawer and Lachman tests frequently demonstrate and gluteus muscles. Core strengthening exercises may also increased ligamentous laxity, although the Lachman test may have benefit. These strengthening exercises should be contin- be most useful in the acute setting (see Table 38). The pivot ued after pain relief. shift test can be used to assess joint stability. Radiography should be performed to evaluate for possible accompanying tibial avulsion fractures, although MRI is often obtained as e Patients with acute anterior cruciate ligament tears well. Anterior cruciate ligament tears frequently require sur- often cannot bear weight immediately and develop gical reconstruction, especially in active patients or those large effusions within 2 to 3 hours. with an unstable knee. A nonoperative approach may be e Anterior cruciate ligament tears often require surgical appropriate as a 3-month trial or in older and less active reconstruction. patients. ¢ Most medial collateral ligament and posterior cruciate HVC Medial collateral ligament (MCL) tears typically involve a ligament tears can be managed conservatively. lateral blow to the knee causing valgus stress, whereas poste- e Patellofemoral pain syndrome is characterized by poorly rior cruciate ligament (PCL) tears involve a posteriorly directed localized anterior knee pain and/or stiffness with pro- force applied to the proximal anterior tibia with the knee longed sitting, climbing, or descending stairs, and with flexed. Increased MCL laxity suggesting a tear may be detected running or squatting; treatment may include activity by applying a medially directed force with the knee flexed at modification, cryotherapy, and physical therapy. 30 degrees (valgus stress test). Increased PCL laxity may be detected by applying a posteriorly directed force to the proxi- mal tibia with the knee flexed at 90 degrees. Most MCL and Bursitis PCL tears can be managed conservatively. Prepatellar bursitis presents as acute or chronic swelling ante- Meniscal tears usually result from an acute twisting knee rior to the patella. Acute cases are often associated with ten- injury or can develop more insidiously as a result of chronic derness, warmth, and erythema. Most cases of acute prepatel- degeneration. Degenerative meniscal tears are often identified lar bursitis are caused by infection with skin bacteria and less incidentally on imaging. Symptoms of a meniscal tear include commonly by trauma and gout. Chronic prepatellar bursitis is pain, locking, catching, and grinding. Patients with acute usually caused by trauma, although gout and infection are meniscal tears are usually able to bear weight immediately. possible. All patients with prepatellar bursitis regardless of On examination, effusions, if present, are generally small to duration should undergo fluid aspiration and analysis. Septic moderate in size. Results of specialized tests, such as the bursitis is managed with knee immobilization, systemic anti- medial-lateral grind and Thessaly tests, are often positive (see biotics, and re-aspiration if needed. Gouty bursitis is managed Table 38). Imaging may not be necessary for diagnosis unless with appropriate gout therapy (see MKSAP 19 Rheumatology). surgery is being considered. Initial management of both acute Traumatic bursitis is managed with activity modification and chronic meniscal tears is conservative and consists of rest. (avoidance of kneeling) and NSAIDs. ice, and strengthening the quadriceps and hamstring muscles. Pes anserine bursitis (pes anserine pain syndrome) is For osteoarthritis-related meniscal tears, physical therapy is as characterized by pain and swelling of the region overlying effective as partial meniscectomy in relieving pain. Surgery is the proximal medial tibia several centimeters distal to the reserved for patients with persistent (+4 weeks) mechanical knee (Figure 18). It commonly occurs in athletes, especially symptoms. runners, and in patients with knee osteoarthritis. First-line

with an unstable knee. A nonoperative approach may be e Anterior cruciate ligament tears often require surgical appropriate as a 3-month trial or in older and less active reconstruction. patients. ¢ Most medial collateral ligament and posterior cruciate HVC Medial collateral ligament (MCL) tears typically involve a ligament tears can be managed conservatively. lateral blow to the knee causing valgus stress, whereas poste- e Patellofemoral pain syndrome is characterized by poorly rior cruciate ligament (PCL) tears involve a posteriorly directed localized anterior knee pain and/or stiffness with pro- force applied to the proximal anterior tibia with the knee longed sitting, climbing, or descending stairs, and with flexed. Increased MCL laxity suggesting a tear may be detected running or squatting; treatment may include activity by applying a medially directed force with the knee flexed at modification, cryotherapy, and physical therapy. 30 degrees (valgus stress test). Increased PCL laxity may be detected by applying a posteriorly directed force to the proxi- mal tibia with the knee flexed at 90 degrees. Most MCL and Bursitis PCL tears can be managed conservatively. Prepatellar bursitis presents as acute or chronic swelling ante- Meniscal tears usually result from an acute twisting knee rior to the patella. Acute cases are often associated with ten- injury or can develop more insidiously as a result of chronic derness, warmth, and erythema. Most cases of acute prepatel- degeneration. Degenerative meniscal tears are often identified lar bursitis are caused by infection with skin bacteria and less incidentally on imaging. Symptoms of a meniscal tear include commonly by trauma and gout. Chronic prepatellar bursitis is pain, locking, catching, and grinding. Patients with acute usually caused by trauma, although gout and infection are meniscal tears are usually able to bear weight immediately. possible. All patients with prepatellar bursitis regardless of On examination, effusions, if present, are generally small to duration should undergo fluid aspiration and analysis. Septic moderate in size. Results of specialized tests, such as the bursitis is managed with knee immobilization, systemic anti- medial-lateral grind and Thessaly tests, are often positive (see biotics, and re-aspiration if needed. Gouty bursitis is managed Table 38). Imaging may not be necessary for diagnosis unless with appropriate gout therapy (see MKSAP 19 Rheumatology). surgery is being considered. Initial management of both acute Traumatic bursitis is managed with activity modification and chronic meniscal tears is conservative and consists of rest. (avoidance of kneeling) and NSAIDs. ice, and strengthening the quadriceps and hamstring muscles. Pes anserine bursitis (pes anserine pain syndrome) is For osteoarthritis-related meniscal tears, physical therapy is as characterized by pain and swelling of the region overlying effective as partial meniscectomy in relieving pain. Surgery is the proximal medial tibia several centimeters distal to the reserved for patients with persistent (+4 weeks) mechanical knee (Figure 18). It commonly occurs in athletes, especially symptoms. runners, and in patients with knee osteoarthritis. First-line 63