Facilitated MSK US examination
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www.usask.ca Musculoskeletal Ultrasound: Moving you forward … faster Patrick Ling, MD, MPH, CCFP(EM), FCFP, RMSK Associate Professor, Family Medicine April 3, 2016 1 st Annual SONO Symposium
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Transcript of Facilitated MSK US examination
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Musculoskeletal Ultrasound:Moving you forward … fasterPatrick Ling, MD, MPH, CCFP(EM), FCFP, RMSKAssociate Professor, Family Medicine
April 3, 2016 1st Annual SONO Symposium
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Disclosures• none
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Traditional Approach to Diagnosis and Management of MSK Condition
1. Patient presents with a painful condition2. History and physical3. Tests
a. Special testsb. Imaging
4. Treat the condition
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Eg: Shoulder Impingement Pain• Patient presents with painful shoulder – impingement type
symptoms• History, Perform clinical tests
• Inspect, palpate, ROM• Special tests• Impingement tests (Neer, Hawkins, Jobe)
• tests: xray? Ultrasound?• Management: NSAIDS, activity modification, PT, cold
compresses? referral?
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Differential Diagnosis• Rotator Cuff tear (acute, chronic)• Subacromial bursitis• Rotator cuff tendinosis• Labral pathology• Internal impingement• Referred pain• Scapulothoracic dysfunction• Adhesive capsulitis• Calcific tendinopathy• Osteoarthritis (glenohumeral, acromioclavicular)
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Clinical Tests• Neer Impingement SignSens 80%, spec 50%+LR 1.7
• Painful arcSens 75%, spec 65%+LR 2.25
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Clinical Tests• Hawkins Kennedy (sens 60%, spec 60%, +LR 1.6)
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More Clinical Tests• Jobe ‘empty can’• Cross body adduction• Drop arm test• Lag test (RC integrity)• Lift off test (RC integrity)• O’brien’s, Crank (labral testing)• Speed’s, Yergason (bicep injuries)• Anterior load and shift, apprehension, drawer, sulcus test
(instability)
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More Tests• Ultrasound
• ‘use dependant’• MRI
• Availability• Treatment ‘test ’ – trial of physical therapy
• Costs, time, clarity on diagnosis• Test of time
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Further Complexity and Confusion• Which clinical test?• Which imaging test?• Reliability (inter-rater reliability)
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Facilitated Ultrasound Examination“ Sono – Exam “
• Combination of clinical examination and sonographic examination
• Ability to visualize the pathology• Ability to do dynamic examination, impingement
testing• Ability to comparative contralateral exams (if
applicable)
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Anterior shoulderPain generators: bicep tendon, tenosynovitis, anterior portion of SASD, subcoracoid bursa, pectoral major tendon
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Shoulder Bursae
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Impingement• Bursal• Bony• compression
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Rotator Cuff integrity• Dynamic stress imaging
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On Field Assessment• Shoulder posterior dislocation (Mackenzie 2013)
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Lower Extremity
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Assessment of Ligamentous Laxity• MCL valgus stress test (Kleinbaum, 2008)
• Ankle lateral ligaments (Gun 2013)
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MCL – LCL dynamic• Dynamic imaging
• Valgus/varus stress • Laxity
• Ligamentous tears
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Anterolateral Talofibular LigamentATFL tears
• Laxity
• Instability
• Important for prognosis & management
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More Information• AMSSM – Position Papers 2014
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More Information• American Registry for Diagnostic Medical
Sonography
• American Institute of Ultrasound in Medicine
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