History
Pain (location, when are symptoms present, how long have symptoms been present, quality, radiating, associated symptoms, aggravating/alleviating factors). Instability. Injury (mechanism, when, sport). Treatments (injections, PT, bracing, medications). Presence or absence of mechanical symptoms (catching/clicking/popping/locking). History of prior surgery to that body region.
Shoulder: worse with overhead activity (impingment), certain movements, instability. Pain at night, pain laterally (RCT).
Knee: mechanical sx (meniscus). Instability (ligaments).
PMH
Heart, lung, liver, kidney disease. Diabetic. RA. Gout.
Medications
Especially anticoagulants
Allergies
Steroids, NSAID’s, etc.
SH
Tobacco use, employment, athletic activities
FH
ROS
PE
Knee
Position of patient supine on exam table
With everything, go back and forth from normal side to pathologic side (especially with ligaments).
General: inspection (skin, contour, swelling, wounds/scars, color). ROM. Obesity.
Anterior knee pain: Palpate inferior pole of patella with knee flexed 30 deg (patellar tendonitis). Pain at top of patella (quad tendonitis). If you push down on top you can better palpate inferior pole and vice versa. Medial plica off medial border of patella above medial joint line can be felt as a palpable band. Finger on either side of patellar tendon and push the fat pad posteriorly while bringing the knee from flexion to extension will cause pain [Hoffa’s impingement (patellar tendon fat pad impingement with fat pad fibrosis)]. Patellar compression or crepitance at varying compression angles causing pain may indicate patellofemoral chondromalacia.
Extensor mechanism alignment: knee in extension tilt patella up to neutral by lifting up on lateral side (if it does not get to neutral, then tight lateral structures). At 30 degrees of flexion push laterally and medially and determine how many quadrants the patella can be moved, indicating either tight or loose restraints either medially or laterally. Note apprehension. Tubercle sulcus angle with knee at 90 deg, foot in neutral. Look at center of patella and center of tibial tubercle (want that line to be neutral or slightly varus). If valgus and patellar instability, requires distal re-alignment. If neutral, patellar instability related to medial laxity or lateral tightness. Move from 0-90 flexion and watch patellar tracking (J-sign when patella is subluxed in extension and as flexion is increased patella comes up and medial to reduce into groove).
Ligaments: Start in 90 degrees of flexion with step off of plateaus (equal side to side [symmetry]). Posterior drawer is next (because everything else will hinge on the PCL being intact or not intact). If posterior drawer is positive (PCL damage, bring tibia to neutral [make step offs normal] and push posteriorly straight back), is posterolateral drawer (posterolateral instability, bring tibia to neutral ER and posterior directed force on tibia) or posteromedial drawer (posteromedial instability, bring tibia to neutral IR and posterior directed force on tibia) positive. If there is an isolated PCL tear you will not have any axial rotation at 90 degrees of flexion.
In full extension lift up on the heels (or big toes) and see if they go into any recurvatum or external rotation (indicating posterior/posterolateral instability). Then holding down on thigh, lift uninvolved heel off of the table and measure the clearance (in cm), then go to injured side and do the same and compare the distance the heel comes up off of the table.
At that point, looking for a stable hinge. In hyperextension valgus and varus stress. At zero and 30 degrees do the same thing. Test varus and valgus stress by cradling the arm between your side and your elbow and your fingers can be placed on the joint line while rotation and flexion are controlled and the fingers can feel the gapping produced by stress. Hyperextension (posteriorlateral and medial capsules are under tension) gapping indicates cruciate and capsular insufficiency. At zero degrees some tension is taken off the capsule and placed on posterior oblique ligament and popliteus tendon. At 30 degrees of flexion isolates superficial medial collateral ligament (valgus) and fibular collateral ligament (varus).
By changing the flexion you are rotating different parts of the capsule under tension throughout the arc (moving your fulcrum point).
You should be thinking of different planes of motion and where the deficiency is throughout the exam.
Posterior instability, axial rotation instability, varus and valgus instability.
Lachman test (at 30 degrees of flexion). If PCL tear is present tibia will be posteriorly subluxed and you will be moving forward from a posterior position rather than neutral position giving a sensation of anterior displacement that is not there. Coming forward if there is a good endpoint (firm snap), ACL is probably intact, whereas if there is no good endpoint ACL is gone. Pivot shift place foot between body and elbow with knee straight and support calf with flat palm of hand. With ACL tear the tibia will be sitting forward and as you flex patients knee gravity will cause the tibia to shift back. Another way to perform test is to start in the same position but have the patient flex hamstrings which will cause the tibia to reduce on the femur.
Hips and knees flexed 90 degrees, supine, PCL and PLC will show increased ER of involved side. At 30 degrees PLC tear will show increased ER here but with isolated PLC tear (PCL intact) no increased ER side to side at 90. But with supine test you are taking tibia backwards with gravity so if there is a PCL tear you are putting capsule under tension which may dampen the amount of spin that you see. If you switch to prone position with knees flexed to 90, then at 30 and test ER you take gravity out of the picture (posterior capsule no longer on stretch). When done in a seated position gravity takes tibia toward the floor and in a neutral position. You can watch whether the medial condyle is coming forward (posteromedial instability) or whether lateral condyle is going backwards (posterolateral instability). This is especially helpful when there is an ACL tear in the presence of a positive dial test.
Meniscus: at 90 degrees of flexion palpate medial and lateral joint line. Lift foot off of bed and ER foot (moves PM plateau forward and posterior horn of medial meniscus is pinched between femur and tibia). By IR of the foot you relieve that pressure by moving the posteromedial plateau away from the condyle. The opposite is true on the lateral side (IR causes pinch and pain, ER relieves pain). By placing an axial load with your rotation you can turn a small tear into a bigger tear. So rotation is really all you need.
Shoulder: ROM full and symmetric bilaterally vs ROM decreased; ROM _____ (IR/ER/FF/ABD); tenderness to palpation at the lateral edge of the acromion; TTP AC joint; TTP biceps tendon; pain with motion; + Hawkins sign with pain within the impingement arc (30-120); crepitus with ROM; Normal contour vs. abnormal contour; positive empty can test vs. negative empty can test (supraspinatus); positive hornblower test vs. negative hornblower test (infraspinatus); positive belly press test vs. negative belly press test (subscapularis); positive apprehension test vs. negative apprehension test (instability); positive relocation test (pain goes away, instability); cross arm adduction test (pain over AC joint); resisted shoulder flexion with arm adducted (O’Brien); resisted FF with palm up (biceps tendon)