Introduction: American Medical Society for Sports Medicine (02:29)

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The AMSSM recommends using research and data to improve quality. Today's lecture looks at evidence-based exam techniques and treatment options.

Evidence Based Shoulder Exam: Dr. John O'Kane (02:53)

Eric Hegedus published a meta-analysis review of shoulder exam studies and applying the QUADAS-2 tool to rate the studies as low, moderate, and high bias. Dr. John O'Kane explains how to use positive and negative likelihood ratios to interpret patient conditions.

Meta-Analysis of Diagnostic Challenges with Variable Pathology (03:11)

Dr. O'Kane discusses Hegadus' review of subacromial impingement, SLAP lesion, anterior instability, and labral tear in terms of sensitivity, specificity, and likelihood ratios. Tear morphologies vary; normal superior labral variability challenges MRA specificity; and arthroscopy yields controversial results.

Test with Potential from Low Bias Studies (04:32)

Dr. O'Hare discusses how to use the shoulder shrug sign, bony apprehension test, belly off test, external rotation lag sign, modified dynamic labral shear SLAP test, passive distraction test, and the active compression for SLAP test.

Combining Tests and Findings (01:27)

Dr. O'Hare explains why combining passive distraction and active compression yields more information about SLAP; combining apprehension and relocation yields more information about anterior instability; and patient age, painful arc, and self-reporting of popping and clicking yields more information about supraspinatus tendinopathy.

Rotator Cuff Strength Testing (01:25)

Dr. O'Kane discusses a 2009 study using ultrasound and cuff dynamometry correlating age with tear probability.

Age and Shoulder Pain (01:23)

A 1994 study of 272 patients found that certain diagnoses fall into certain decades with a ten year standard deviation.

Imaging for Rotator Cuff Tears (01:58)

Dr. O'Kane argues that MRI and ultrasound are effective at ruling out partial and full thickness rotator cuff tears; MRAs are appropriate for SLAP lesions. The combined passive distraction and active compression test has better likelihood ratios than the MRA.

Evidence Based Shoulder Exam Algorithm (01:50)

Shoulder tests debut well; performance deteriorates with time and scrutiny; the soft test performance is the gold standard; and imaging is not necessarily the answer. Dr. O'Kane presents a diagram for assessing and diagnosing shoulder pain and shows his references.

First Time Shoulder Dislocations: Dr. Eric McCarty (02:11)

Dr. Eric McCarty makes speaker disclosures and acknowledges professional collaborators.

Kansas City Shoulder Case (03:34)

A high school quarterback sustained a dislocation but the shoulder slipped back into place. Shoulder instability is common in sports; Dr. McCarty discusses traumatic and atraumatic reduction methods.

Managing Shoulder Dislocations (02:38)

Dr. McCarty cites studies showing that immobilization does not reduce recurrence rates, and discusses internal vs. external rotation during immobilization. A meta-analysis shows patients under 30 do not benefit from immobilization, and are likely to suffer recurrences.

Obtaining an MRI (01:11)

A high school quarterback suffered a GLAD lesion after a dislocation. He was immobilized for one week and had good motion, mild apprehension and good strength. Considerations for returning to play include safety and further injury risk.

Criteria for Returning to Play (02:16)

Following a shoulder dislocation, there should ideally be little pain, near normal range of motion and strength, normal functional ability, and normal sports specific skills. Athletes may need counseling, continued rehabilitation, and support braces.

Recurrence Rate (02:03)

Dr. McCarty cites historical studies showing higher recurrence rates in younger patients with non-operative treatment. Arthroscopic surgery lowers the recurrence rate after first time dislocations.

Arthroscopic Stabilization Technique (04:19)

Dr. McCarty cites a study showing that arthroscopic Bankart surgery is more effective than open surgery. He shows a video of the operation to re-tension the inferior glenohumeral ligament. Surgery is not indicated for large glenoid defects.

Kansas City Shoulder Case Summary (01:48)

A high school quarterback had a traumatic SLAP lesion with a normal rotator cuff. Dr. McCarty shows images of his arthroscopic stabilization surgery. He completed his football season with a harness; learn about his post-operative rehabilitation.

Knee Exam Challenges (04:11)

Dr. Joseph Garry outlines variability in exam maneuvers, and poor inter-rater reliability due to inexperienced physicians. Composite examinations may be superior to MRI. Reference standards, reporting bias, patient population, small sample sizes, and pathology heterogeneity are also limitations.

Anterior Cruciate Ligament (02:45)

A negative Lachman test rules out an ACL rupture and the pivot shift rules in an ACL tear. The anterior drawer is effective for chronic ACL tears, and the prone Lachman test has good inter-rater reliability.

Medial Collateral Ligament (01:04)

Clinical judgment and valgus stress testing leads most physicians to diagnose an MCL injury. It can be excluded in the absence of pain or laxity.

Posterior Cruciate Ligament (00:51)

The posterior drawer is the most accurate PCL test in terms of sensitivity and specificity.

Meniscal Exams (03:04)

Dr. Garry explains why McMurray and Apley testing produce mixed results. Joint line tenderness and a positive Thessaly test in a 20 degree flexion may be the best tests for the meniscal exam.

Patellofemoral Instability (01:34)

There has been little evaluation of instability testing. Patellofemoral pain tests have positive and negative likelihood ratios unlikely to change pretest probability of whether or not the patient has pain.

Arthritic Knee (01:12)

Ligamentous testing, including the Lachman, pivot shift, valgus stress, varus laxity and stability tests are unreliable in end stage osteoarthritis. Dr. Garry suggests that other intra-articular knee pathology could also affect tests.

Knee Exam Summary (00:35)

A negative Lachman test rules out an ACL tear and a positive pivot test confirms one; a negative Valgus stress test at 30 degrees rules out an MCL injury; and a posterior drawer is best for a chronic PCL tear.

Knee Exam Future (02:09)

Dr. Garry recommends using detailed questionnaires, taking composite histories as in primary care settings, developing protocol based evaluations, and using predictive modeling.

First Time Acute Patellar Dislocations (03:27)

Dr. Beth Shubin Stein provides an overview of young patients suffering knee trauma. She will discuss trochlear dysplasia, articular geometry, the tibial tuberosity-trochlear groove (TT-TG) and the medial patellofemoral ligament (MPFL) anatomy in terms of patella stability.

Acute Patellar Dislocations (00:27)

The patient cohort includes males and females in their teens and twenties suffering a twisting non-contact injury.

Acute Patellar Dislocation Physical Exam and Imaging (02:42)

Patients will have swollen and ecchymotic knees; MPFL tears are always on the medial side. Dr. Shubin Stein recommends MRIs for greater traumas to identify cartilage damage.

Natural History (02:01)

Studies find varying rates of acute patellar dislocation recurrence. However, having both skeletal immaturity and trochlea dysplasia increased recurrence rates among children under 18. Dr. Shubin Stein shows chondral injury images indicating surgery.

Who Needs Surgery? (03:11)

Dr. Shubin Stein discusses studies recommending both operative and non-operative treatment to reduce acute patellar dislocation recurrence rates. The current consensus is to not operate on first time dislocators.

Patella Instability Surgical Options (03:02)

Distal realignment is not effective for first time dislocators. MPFL repair is indicated for loose bodies or osteochondral fracture, but MPFL reconstruction has better results. Arthroscopy can realign cartilage, while isolated lateral release is only indicated in conjunction with stabilization.

Q/A: Resetting Shoulder Dislocations (03:31)

Dr. McCarty recommends putting patients prone on a table and hanging weights on their arms as an atraumatic resetting method. Muscles will surrender with patience. Dr. O'Kane recommends having patients sit up and hug their knees as a self-reduction technique.

Q/A: Imaging and Immobilization (01:38)

Dr. McCarty recommends not using dye for first time shoulder dislocators. Dr. Shubin Stein describes her non-operative treatment regime for first time knee dislocators, including joint aspiration and weight-bearing exercises.

Q/A: Repairing Dislocations (02:37)

Some hyperelastic shoulder patients do not have Bankart lesions. Dr. McCarty does MRIs for these first time dislocators, and only repairs and plicates them in case of recurrence. Dr. Shubin Stein discusses first time patella dislocators without MPFL tears.

Q/A: Literature Review (01:12)

Dr. O'Kane found studies used MRI and direct visualization with arthroscopy to correlate physical exams to pathology.

Q/A: Knee Reconstruction vs. Repair (01:44)

Dr. Shubin Stein reconstructs MPFLs of first time child dislocators with open growth plates and trochlear dysplasia if she is doing surgery for another reason.

Credits: Lost and Found: The Evidence Behind Our Musculoskeletal Exams and Treatments (00:26)

Credits: Lost and Found: The Evidence Behind Our Musculoskeletal Exams and Treatments