Ortho on the go
Ortho on the go
Importance of functional exam in orthopedics
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves.
SPEAKER_01Today's episode, uh, I thought we would do a case presentation, but a little bit of a conversation regarding the importance of physical exam and functional orthopedics. I'm lucky enough to have a background in athletic training. I think with this athletic training background, at least to start off before PA school, I learned a lot in the importance of kind of functional examinations regarding sports-related or more athletic-related injuries. I think over the years, um, as I've become more comfortable in orthopedics and kind of felt more confident in my orthopedic education, I've started to use these functional exams to a lot of the times tease out the cause and a root cause for a lot of injuries that happen. Again, I think it's important to take this into consideration. You know, the mechanism of injury or the onset of injury is probably one of the most important things I try to uh nail down when seeing a patient in clinic. If somebody comes in and sees me, uh the first thing I ask them about is, did you have an injury, some kind of uh exciting incident, a fall, a trauma, something like that that caused the pain to occur? Because most of the time, if they had an injury that caused the pain to occur, then usually you're gonna be worried about a more structural problem, a tear, a sprain, uh, some type of cartilage injury, whatever it may be, whatever joint may be affected. And then if there is a specific injury, I'll always ask about the mechanism regarding that injury. You know, what exactly happened? Were you struck on the outside aspect of the knee and sustained a valgus force to the knee? Was it a non-contact flexion rotational injury playing soccer? Did somebody feel like they kicked you in the back of the leg for an Achilles-type injury? You know, as we've said before, common things happen commonly. And a lot of the times with these injuries, if you can nail down the mechanism of the injury, you can typically nail down the diagnosis. If we know our anatomy well enough, we can know based upon the mechanism of injury potentially what structure has been injured. So, you know, when I have students come in or I'm talking to people about orthopedics, for me, again, the mechanism of injury is a very, very important part for me to help wrap my mind around what potential structure could be injured. So if somebody comes in with an acute injury, again, I'll nail down the mechanism of injury, I'll go over their physical examination, I'll make sure to palpate in the areas that I think are structural things that could be injured. And I try to piece together my mechanism of injury with my palpation to potentially, you know, form a diagnosis of what could be going on. But a lot of patients don't come in with injuries. They say, hey, I woke up and the pain occurred. Hey, the pain has gotten progressively worse over time. Um, I've been doing more of this activity and now I've noticed the pain. Uh typically these are more inflammatory, overuse, muscle imbalance type symptoms. They're not structural necessarily symptoms. Sometimes it's hard to wake up with pain that you don't remember doing anything the day or two days before and have a structural tear or a ligamentous injury. So often in these patients, um, I'll do more of a functional examination in the clinic to see if there's some kind of imbalance that potentially is contributing to their symptoms. So I had two interesting cases come in. The first one was a uh 15-year-old gentleman who came into clinic, he was a jiu-jitsu athlete, and he said every time after doing jujitsu or a lot of lower extremity activities, he would develop pain within his knee. The pain would occur mostly on the lateral aspect of the knee or the outside aspect of the knee, and would typically resolve overnight with anti-inflammatory medications and rest and modified activities. Occasionally, if he did a heavy lifting day for squat activities, the pain and the pain would remain and cause some limited activities the following day, but then again, would typically resolve. So, again, based upon this presentation, you know that the mechanism only happens after doing jujitsu activities. That's an overuse type mechanism, an inflammatory type mechanism. And the fact that he can treat it and it typically resolves the next day, again, probably leads me to believe it's more inflammatory, overuse, some type of mechanical imbalance mechanism, and unlikely to be a structural thing, because if you tear your meniscus, that kind of hurts most of the time when you're weight bearing. Structural things tend to hurt consistently and continually. Soft tissue things tend to hurt intermittently in nature. So for him, based upon his mechanism and his presentation, I knew, hey, this is a patient I probably want to do more of a functional examination as well as my typical, you know, knee examination. So I went through my typical knee examination. I palpated kind of throughout his knee. Um, he had some lateral patello femoral pain, his patella was tracking centrally, he had no joint diffusion noted, he had full unrestricted active and passive range of motion, he had no instability of stress testing of his knee. So with these situations, you normally say, Well, I'm not sure what's going on. I could get an MRI just to make sure there's no underlying structural damage. But again, is the MRI going to change what we're gonna do? I tend to not order tests that aren't gonna change what I'm gonna do. If the MRI does come back showing some subtle findings, is this something we're probably gonna do surgery on with a patient that has such intermittent symptoms, although yes, progressively getting worse? Normally my answer in my head would be no to that. So for this patient, I um advised that we do a more functional exam. So for him, I checked his hip range of motion. So I have him lie down on his back in a supine position, I flex his hip up and I internally, externally rotate his hip. And his hip on the injured side was much more restricted with internal rotation than the uninjured side. So then I'll get him up into a figure four position or I'll have him kind of cross, you know, one leg over the other, figure four, again, checking to see if there's adduction, um, you know, a tightness andor internal rotation tightness, which again he had on his left side. So then I'll have him stand up and do a squat test. So I'll just have him do an air squat. And so when he air squatted, he significantly shifted his hips towards the opposite side, trying to favor the side that was painful for him. Uh when I had him do single leg stance activities, so hold one hand onto the table and balance with a single leg just on one side, you could see there was a noticeable hip drop uh when he tried to balance and hold his left side up compared to his right side, the left side being the affected side. And then when I had him do a single leg squat activity, that significantly exacerbated his symptoms, caused increased pain within the patellofemoral area, and he had noticeable valgus and kind of loss of coordination with this. So for him, he's complaining of pain within the knee, especially with heavy squatting activities. Again, I explained to the patients, it's hard to see what came first, the chicken or the egg. Is he doing these compensatory activities because he has pain within the knee? Or are these compensations causing the pain? And I think it's a little bit of both. But for him, he has noticeable soft tissue deficits and functional deficits on one side compared to the other side, which are likely contributing to the symptoms he's complaining of. And so I think he would benefit quite a bit from physical therapy activities that trying to improve the mobilization within that hip area, um, as well as improve the strength within that hip posture chain, gluteus medius area that we all tend to ignore. A lot of these athletes that come in and complaining of lower extremity pain, that's more of this gradual onset, you know, exercise-related pain, they tend to have weakness within their gluteus medius. They tend to have weakness with single leg stance activities, they tend to have weakness within their adductors that typically cause the pain to occur. So these are all patients that do quite well with physical therapy activities. So for him, we sent them to physical therapy. Um, they were able to correct some of these deficits. He was able to get some symptomatic relief. Again, I think the thing to remind patients for this is they should notice some beneficial relief out of physical therapy after two to four weeks. But these things take time to get better. This could take two to three months, if not longer, for them to get complete resolution of their symptoms. But it potentially is something that they can continue to work through, exercise through, participate in their sports through, and do the corrective activities if we can get them out of the acute pain that was restricted for them, at least initially, why they presented to the clinic. So this is a classic case of a patient that comes in more of an insidious onset of pain within the lower extremity. And a lot of times I like to do these single leg activities, these balance activities, these squatting activities to see if they have deficits with these activities, check their hip range of motion, check their adductor strength, check their glute bridge strength on that side to see if there's weaknesses, and potentially that's contributing to their symptoms. Another patient very similarly came in complaining of shoulder pain. He was a fratty um athlete, so an upper extremity kind of athlete. He complained of pain, but pain was in the periscapular muscles around his left shoulder. He doesn't specifically remember a fall, a trauma, an injury. He states he was in an armbar slash arm lock type activity and did feel kind of a pain within the shoulder area. So similarly, you know, I like to visually evaluate the patients and their kind of normal stance, their normal posture. So I have them all sit with both hands on their lap and I kind of see if one shoulder is lower than the other. And normally the dominant arm is going to be lower than the non-dominant arm because the dominant arm is going to do a lot more overhead activities and the tissue is going to be a little bit more stretched out. So if the non-dominant arm is lower, this could represent some type of soft tissue imbalance or injury to the area. But most patients that come in complaining of pain, they hold that painful side into kind of a more up kind of, you know, protected position. And then I had him kind of forward flex and abduct his shoulder and or his arm. And immediately noticed that when he did these activities, he he hiked his shoulder up. He used his trapezius to do a lot of the initial initiation of the forward flexion and abduction activities. Now again, is this a painful thing that he's trying to compensate for? Or is this something that he had a soft tissue injury to this posterior periscapular area, and now he's doing this, you know, trapezius shoulder hiking activity to try to improve his symptoms. Um, so that was the first thing I noticed. His rotator cuff strength was great. The rest of his physical exam was good. He had some mild pain with speeds, Jurgensen's O'Brien's type testing, but his symptoms were clinically concerning for superior labral tear, labral pathology, proximal biceps pathology. He didn't have any instability sensations within his shoulder. And so I always then have the patient either take the shirt off or leave their shirt on, depending on whatever's comfortable for the clinic environment. But I have him face away from me and I have him do forward flexion and abduction again, and I look at their scapula, I look at their shoulder blade, and look at the rhythmic movement of the shoulder blade. Well, for him, you could you could see significant scapula diskinesis. His left shoulder blade was arrhythmic compared to his right, and he would, he, you know, when he was especially lowering down, he would wing his scapula and you could see it would kind of modify over to reduce this painful arc that he knew that he had. So again, I explained to the patient and their family members, it's hard to tell if this is compensation due to him having a painful spot in his shoulder, or if this has potentially just, you know, been exacerbated over time with him doing all these compensatory activities. But I think this is something that needs to be corrected. Even if it does show some internal pathology within his shoulder and an MRI, we would ideally like to correct this prior to proceeding with any surgery, as this can then cause complications after the surgery. And one of the big things about this, especially with young athletes, is I show the parents, I say, hey, come here, look at what, look at what's going on. And you can visually see the arrhythmic difference between the shoulder blades. You can visually see the shoulder hiking going on as the previous patient. You can visually see the shifting from one side to the other with squatting activities or the imbalance with the single leg activities. And if you give them this visual feedback, they're going to be more prone to want to participate in physical therapy activities and know that these could be beneficial for their child or their patients. So for this gentleman, the same thing. Now, one thing I like to do with these patients is I like to stabilize the scapula. So I'll put my hand on that shoulder blade, I'll hold that shoulder blade down, and I'll put my other hand kind of on the front of their chest area there, and I'll have them forward elevate and abduct again and see if with stabilization of the scapula, their symptoms will improve. And for him, his symptoms did noticeably improve. And so that tells me that if we can stabilize the scapula by improving his scapular dyskinesis and the arrhythmic motion of his scapula, then a lot of the times we can make his pain better because we know that that's probably contributing or leading to some of the pain that he's having. So this is another patient that again sent to physical therapy. Um, they addressed the issues. We told them that it's going to take a long time. No scapular dyskinesis can take three, six months for them to get better. But ideally, we can improve his symptoms, allow him to participate in some sporting activities while throughout the therapeutic activities and see how things progress. So these are two patients I thought would be really good to kind of discuss. One I often see that I do these functional exams on quite a bit is lower back pain, especially in my cheerleaders and my gym nose. Now, again, a lot of these lower back pains, if they're acute on onset, could be concerning for parse defects or stress fractures in the pars or spine type abnormalities. But a lot of them can be these, again, functional deficits. I had a cheerleader come in the other day. She was 16. She was the base, so she was holding the other individuals above. And every time she would do that andor participate in cheerleading activities, then not necessarily the bending type activities, the flipping, the back bends, but just cheerleading in nature, especially the pounding of cheerleading, she would have lower back pain, SI joint pain. So again, did the full functional evaluation, as we've discussed before, check hip range of motion. She had a lot of limitations in her range of motion on the affected side. She had some increased pain with these functional activities. I think most of her pain was coming from her SI joint area. So we sent her for physical therapy. But one of the important things I talked to her about was the bracing of the abdomen when doing these activities, because a lot of the times, if she's not bracing her abdomen appropriately and her core appropriately, when she's going to lift these other individuals above her head, then she's going to put a lot of stress across the structure of her of her spine. And if she puts stress across the structures of her spine and the muscles are not there, it's dynamic stabilizers to support her, then she's probably going to have some increasing symptoms. So I think these are important things to think about. Again, don't do these necessarily functional evaluations on patients that come in complaining of acute injuries and loss of range of motion, because most of the time those are going to be structural abnormalities where you're not going to get much out of this and just cause the patient a lot of harm or a lot of pain. But if patients come in complaining of this gradual onset of symptoms, this gradual onset of pain, I think these evaluations can be quite helpful because they can tease out a lot of these structural and soft tissue abnormalities that likely are causing the pain, likely potentially wouldn't pick up on MRI, andor you may see something on the MRI, but that finding on the MRI is not what's causing the patient's symptoms. So I hope this was helpful. Again, please feel free to follow us on social media, Facebook, Instagram. Please feel free to comment or reach out with any topics andor suggestions you would have regarding the podcast for improvement. And I hope you guys have a good day. Thanks.