NUP Bridging – Ortho 20220819

Shoulder
Expose “I’d like to request a chaperone. Please take off your shirt so I can examine your shoulder.”

Look front and side, wasting of deltoid upper trapezius and infraspinatus. From behind Scapula
winging put hands on wall.

Feel SC joint, clavicle, ACJ, subacromial tenderness (impingement syndrome)

Move Stand in front. “mirror what I’m doing.” Flex extent abduct ER. IR with thumb to T8 internal
angel T4 spine of scapula.

If anytime AROM restricted, attempt passive TRO frozen shoulder.

Strength testing normally done here but skip for consult station. Supraspinatus (thumbs UP
abducted 45deg in scapular plane “push up” and resist). Subscapularis (IR belly press with forearms
and wrists in straight line, “don’t let me pull your elbow away” or Gerber’s lift-off but may also be
impingement). Infraspinatus (resisted ER with palms up “I’m going to push your hands together, try
to push them apart”).

Special

Supraspinatus impingement do all 3 (sensitive but not specific): empty can (abducted in scapular
plane 30deg like hugging a big tree, “push up against my hands”) Hawkins Kennedy (can just adduct
to opposite shoulder and internal rotate by lifting the elbow – pain is positive). Neer (Elbow straight
thumb down, passively forward flex. Pain at end range of motion is positive).

Biceps and labrum injuries: Speed (Shoulder 45 deg forward flex, straighten, resist shoulder flexion
at elbow/biceps tendon. Bicep tendon.) Yergason optional. O’Brien for labrum (forward flex shoulder
90deg, adduct across nose, resisted shoulder forward flexion. With thumb down more pain, thumb
up less pain).

Instability: Anterior apprehension +relocation for anterior instability (standing or lying. Abd to 90
and ext rotate 90, passively external rotate shoulder and apply anteriorly directed force of humeral
head “shoulder might feel uncomfortable, tell me if it feels like it is popping out”. Then reverse by
passively internally rotating and apply posterior directly force on humerus). Sulcus for
multidirectional instability/ligamentous laxity (tug downwards).

ACJ tests: cross abduction and apply pressure on elbow check for pain.

Neck screen – look up/down, left right, sensation over regimental badge (axillary nerve).

Physio for impingement always increase load bearing capacity and reduce cuff flares.

Mx Supraspinatus impingement - isometric - hold bottle of water/resist at 45deg in scapular plane

30s x 5sets. Infraspinatus – isometric ER 30s x 5 sets (till pain score 1-2/10).

Impingement vs. tendinopathy – usually co-exist. But impingement position is 90deg abduct, pure
tendinopathy would be 45deg. Mx – impingement can give subacromial injection. Tendinopathy
focus on physio.
Lumbar spine
Back pain can be from lumbar spine, SI joint, hip

Expose – chaperone. take off shirt.

Standing – Look from side for loss of lordosis (spasm) then behind for scoliosis/listing. Move -
Forward bend test to accentuate kyphoscoliosis. Back should be rounded not flat, otherwise signifies
spasm (or intervertebral joint pathology). Fingertips try to touch floor. Schober’s test only if you
suspect ankylosing spondylitis. Extend (facet joint pathology).

Bend to sides (“mirror me”)

Sit down. Thoracic rotation (cross arms over chest and turn, “mirror me”).

Supine. Neuro LL – SLR then inspect/tone/reflexes/power. Check dorsalis pedis pulses. Screen hip
with FADIR. Screen SI joint with FABER (figure of 4, pain in buttock area is SI joint, pain in groin is
intraarticular).

Prone. Feel midline of spinous processes for step, paralumbar muscles L1 to L5, buttock SI joint along
the triangle lines (“going to press on your buttock to check the joint”), ischial tuberosity. Femoral
stretch test (pain shooting down front of thigh).

Hip
Expose – take off pants

Walk for Trendelenburg gait (lurching upper body/CG over to painful side).

Standing. Trendenlenburg sign (support pt’s forearms from below, “mirror me lift your right foot”.
Sound side sags).

Supine. Square pelvis (bend hips and knees to 90deg, pt lift hips off bed, put knees straight again).
Limb length discrepancy (look at level of medial malleoli 1.5cm or less is normal).

Feel – “Need to press on groin to check for pain”. ASIS + pubic tubercle then cough for hernia.

Move mostly passive some active. Thomas test (hand underneath to obliterate space of lumbar
spine, pt hug both knees to chest, then “straighten your right leg”. If still flexed, passively stretch out
to check for FFD vs muscle tightness). Abduct/adduct passively (left forearm across ASIS, right hand
abduct and adduct from foot.) IR/ER (passively flex hip and knee to 90deg, then IR/ER. Combine with
FADIR hip OA labral pathology AVN. and FABER test).

Decubitus - Lie on side and palpate greater trochanter.

Prone – Feel lumbar spinous processes/paralumbar muscles, SI joints, ischial tuberosities (proximal
hamstring tendinopathy). Move hip extension (flex knee and passively extend hip).
Groin pain and FABER pain but FADIR neg – maybe it’s adductor longus tendinopathy. Palpate the
adductor longus tendon.

Knee
Expose – take off pants, remove socks and shoes,

Walk for antalgic gait

Standing look front/side/back – quadriceps bulk, stand with knees together for genu valgum (risk
factor for AKPS in young) or genu varum (OA), knee flexed due to effusion or pain, baker’s cyst

If young, squat and ask for pain (irritation of PF joint anterior pain, meniscus pain at sides). Don’t do
if old.

Supine

With knees extended. Look for quads wasting, ask pt to push hand into couch on both sides.

Feel + special tests. Quads tendon. Effusion tests (patellar tap, cross fluctuance, patellar bulge).
Patellar tap (milk with left hand, wiggle with right index and middle). Cross fluctuance (both hands,
push between medial and lateral of knee). Bulge (sweep medial to top to lateral, then push back).
Clark’s test/patellar grind (right hand under knee, left hand C shape above patella and push down on
quads tendon while asking pt “press down on my hand”. For grind, barbarically use heel of palm and
grind left and right on quads tendon). Palpate patellar tendon, then patellar tendon insertion. Pes
anserine insertion 1 FB medial and inferior (post menopausal).

Come to side of knee ask pt to lift leg off bed with knee extended. If flexed, move passively to check
whether extensor lag or FFD. Compare to other side. Then ask pt to actively flex all the way, then
back to 90deg.

Feel joint line. Lateral to patellar tendon – lateral joint line tenderness, meniscus tear. LCL (fibular
head to lateral femoral condyle). Medially, medial joint line to meniscus. MCL (medial femoral
epicondyle downwards junction of 1/3 of medial and middle third.

Special. Sag sign for PCL tear. Anterior drawer (index fingers push back to relax hamstring, thumbs
straddling joint line, pull backwards with whole bodyweight). Lachmann’s (left hand hold thigh, right
hand hold proximal tibia with knee in 20deg, feel for looseness. Modify by sandwiching thigh
between your left thigh and left hand). Valgus stress (left heel of palm lateral to knee, passively flex
to 30deg to isolate MCL, right hand valgus stress from distal tibia; pain or gapping is positive). Varus
stress opposite.

Skip Apley grind.

FADIR to screen for intraarticular hip pathology (flex, adduct across midline, internal rotate hip).
For ITB syndrome – Noble’s test thumb pressure over lateral femoral condyle, passively move knee
between 0 and 30deg flexion. Ober’s test for tight ITB (left hand on iliac crest, right hand passively
move hip into flexion and knee should passively adduct and touch table).