key: cord-0694554-mck7ed8f authors: Laskowski, Edward R.; Johnson, Shelby E.; Shelerud, Randy A.; Lee, Jason A.; Rabatin, Amy E.; Driscoll, Sherilyn W.; Moore, Brittany J.; Wainberg, Michael C.; Terzic, Carmen M. title: The Telemedicine Musculoskeletal Examination date: 2020-08-01 journal: Mayo Clin Proc DOI: 10.1016/j.mayocp.2020.05.026 sha: 8b5c48b5e27b11740f23a1c1bb972a3200e7cdb9 doc_id: 694554 cord_uid: mck7ed8f Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform. T elemedicine is the use of modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. 1, 2 Telehealth, which refers to the broader scope of remote health care services, was first introduced in the 1960s and gained popularity in the 1990s as technology improved and associated costs declined. 1, 3 Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing more convenient, safe, and time-and cost-efficient care. 3 Telemedicine is currently applied in multiple settings including, but not limited to, stroke evaluation with large national telestroke networks, cardiology consultations including myocardial infarction evaluation, surgical consultations, psychiatric evaluations and remote mental health monitoring, dermatology consultations, newborn resuscitations, and trauma and emergency medicine care especially in rural or resource-poor areas. 1, [3] [4] [5] Telemedicine has also been found to be useful in the outpatient and inpatient physical medicine and rehabilitation setting. 6 The coronavirus disease 2019 (COVID-19) pandemic has created significant nationwide changes in health care access and delivery. Elective appointments and procedures have been delayed or canceled, and multiple states have shelter-in-place orders. Many institutions now rely on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Furthermore, telemedicine can help reduce the surge in health care needs and visits once restrictions are lifted and reduce the financial strain on medical practices. The medical literature has exploded with information and advice on how to best approach telemedicine visits. This includes a recent article that provides a general approach to the outpatient rehabilitation visit. 7 Another recent publication provides recommendations for the virtual orthopedic examination, including the knee, hip, shoulder, and elbow examinations. 8 Musculoskeletal conditions are extremely common. A recent report suggests that 1 in 2 adult Americans lives with a musculoskeletal condition. This is the same number as those with cardiovascular or chronic respiratory disease combined. 9 Given the frequent presentation of individuals with musculoskeletal complaints to the health care provider, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve even after COVID-19 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. Accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can selfperform. Most of these tests are based on validated physical examination maneuvers performed during face-to-face patient encounters, but have been modified to enable the patient to self-perform the maneuvers. We acknowledge that the sensitivity and specificity for these self-performed and modified tests have yet to be documented, but we have tried to maintain the essential components of the original tests as much as possible. Shoulder, hip, and so on, as clinically appropriate. d The preferred examination framework: B The patient is dressed in shorts and a Tshirt or a similar loose-fitting shirt. B Inquire about the type of electronic device. If a laptop, tablet, or smartphone is used, it is easier to move the device to complete parts of the examination. B A family member or friend: n To assist with a portion of the examination that requires moving; to assist with safety and special tests and camera control. d An assistant may help in raising the shirt to permit viewing of the lumbar spine region. d Pain location: B Does the pain localize to the base of the spine near the posterior superior iliac spine (PSIS) (dimples of Venus) and above? Or mainly below the PSIS? If above, this is typical for most low back pain. If mainly below, consider pelvic pathology. B If there is back and leg pain, document whether the back or the leg component dominates (radicular pain is typically leg dominant). B Document the location of leg pain looking for a radicular distribution. Also document paresthesia location. n L2 / Anterior thigh to mid-distal thigh n L3 / Anterior thigh to knee n L4 / Anterior thigh, anterior or medial shin to medial malleolus n L5 / Later or posterolateral thigh, lateral calf, top of foot and great toe n S1 / Posterior thigh, posterior calf, planter or lateral foot, small toes d Posture: Check while standing in both the coronal and sagittal planes. B Coronal plane: General symmetry; comment on scoliosis, pelvic, and shoulder symmetry. B Sagittal plane: Lumbar lordosis, thoracic kyphosis that can be associated with posterior pelvic tilt (which results in "flat back") or anterior pelvic tilt (which results in "sway back"). B Ideally a view of the entire profile is preferred to assess overall spinal posture, recalling that a plumb line normally falls from the external auditory meatus through the acromion and travels behind the hip and in front of the knee and ankle. B Inspection of the spine and the entire lower extremities is particularly important in a growing child. Look for spinal curvature, thoracic-lumbar prominence, asymmetry of limb length, and asymmetry or abnormality of the foot/ankle that might suggest a neurological problem. In addition, skin inspection for skin fold asymmetry and skin lesions is necessary. B Left convex curves in a child are more commonly associated with neurological or worrisome etiology. Palpation d Palpate with 1 finger to locate low back tenderness. Guide the patient to other landmarks (PSIS, ischial tuberosities, greater trochanter, paraspinal musculature, and spinous processes). d Assess while standing. The patient moves to end range of flexion, extension, lateral flexion, and rotation. Objective measures of lumbar spine flexion can be performed using the estimated or measured distance from the tip of the third digit to the floor. d Alternatively, an assistant can measure the modified Schober's test. Draw a line 5 cm below and 10 cm above the PSISs (also known as dimples of Venus). In an erect posture, there will then be 15 cm between the lines. Ask the patient to bend forward maximally and measure the distance between the lines again. Normally, an additional 5 cm of length is observed, or a total of 20 cm or more between the lines. d In a growing child, assess for thoracic prominence (rib hump). d The single leg sit to stand test to assess for subtle quad weakness in suspected L3 or L4 radiculopathy. d Heel and toe walking to screen for L5 and S1 radiculopathyerelated weakness, respectively. d Repetitive toe raises for subtle S1 radiculopathyerelated weakness. Assess the normal leg and then the painful leg. d For an ambulatory child, try frog jumping (the patient assumes a squatting position with hips and knees externally rotated and fingers/hands to the floor and then proceeding to jumping up, repeating movements to assess for lower extremity strength, ROM, and coordination), single leg hopping (assessing strength, Trendelenburg, knee valgus, and balance), and rise to stand from sitting on the floor (assessing strength and use of hands and arms to assist in rising from a squatting position, as in Gower sign). to grip (make a fist) and release repeatedly, with the palm facing downward. Most healthy adults can perform more than 20 repetitions in 10 seconds. Patients with myelopathy will exhibit a slower rate and may exhibit exaggerated wrist flexion with attempted finger extension and exaggerated wrist extension with attempted finger flexion. 13 d The Spurling maneuver is performed by laterally flexing the neck to the symptomatic side. A positive test reproduces the patient's arm pain/paresthesias in a nerve root distribution. Pain with this maneuver in the posterior neck and cervical paraspinal region only without radicular pain may be seen with facet degenerative changes and myofascial pain. B A common variation is shown with neck extension and rotation to assess for the reproduction of radicular arm symptoms. If pain is not elicited spontaneously, an assistant can apply gentle pressure to the top of the head. These maneuvers should be held for about 5 to 15 seconds if not immediately positive. 14 B For safety purposes, have the patient perform this test in the seated position. d Thoracic outlet test: The Roos stress test involves repeated opening and closing of the hands for 1 to 3 minutes. A positive test reproduces the patient's arm pain symptoms. HIP (SUPPLEMENTAL VIDEO 4, AVAILABLE ONLINE AT HTTP://WWW. Patient Considerations d The patient should be wearing shorts to permit full and unhindered range of motion of the hips as possible. A T-shirt or other similar shirt that will permit examination of the hip and lower back region from the front and behind is also recommended. The examination is performed after the removal of shoes and shocks. d There should be enough room to permit a full-body view of walking both toward and away from the camera. A second person to control camera placement and view is recommended. d A bath towel or similar long length towel can be used to provide assistance for some of the stretches and range of motion assessments during the hip examination. d If this is an examination of a small child, a flat surface where the child can lie down, such as the floor, table, couch, or bed, will be needed. Palpation d Trochanteric palpation can be performed with the patient lying on his or her side, symptomatic leg facing upward, hips flexed to 60 , and knees together, after which the patient feels the lateral hip for tenderness. If the patient is able to lie flat either on a mat on the floor, a sturdy table, or a bed, the following can be examined: and antalgic gait, and assess for feelings of instability or mechanical block. d In an ambulatory child, in addition to the above, observe running, jumping, hopping on 1 foot, single leg stance, and so on. Standing Evaluation d Range of motion: Have the patient pull his or her foot up to the ipsilateral buttock to assess the degree of knee flexion. d Thessaly test to assess for meniscal pathology: Stand on 1 leg using support as needed; bend knee slightly (5 ), and rotate femur and torso medial and laterally 3 times; assess for pain with either medial or lateral rotation. Repeat 20 of knee flexion. d As appropriate and as able, a single leg hop test could be performed and assessed for pain provocation, including at the patellar tendon as well as other specific knee region. Supine Evaluation d Range of motion: Assess the ability to fully extend and flex the knee, evaluating for any extension or flexion lag, which may be associated with swelling or mechanical meniscal involvement. d If able to lie flat with knee at 90 of flexion, the patient can self-palpate areas of the knee to assess for tenderness, including medial and lateral joint lines, patellar tendon, distal quadriceps, pes anserine bursa region, and tibial tubercle (including assessment of swelling indicative of Osgood-Schlatter disease). d Also in 90 of knee flexion, the patients can assess for posterior sag sign indicative of posterior cruciate ligament insufficiency and can perform the quadriceps active test, involving active contraction of the quadriceps to see if sag reduces and if the tibia translates anteriorly. d If able to apply varus or valgus stress with the opposite limb or stationary object, the patient can further assess the degree of medial collateral ligament or lateral collateral ligament sprain; assess for pain and opening. d The patellofemoral joint can be assessed while lying with the knee extended and quadriceps relaxed. The patient can gently push the kneecap medially and laterally to assess for femoral condyle or patellar facet tenderness. d Range of motion: Seated range of motion can be assessed via ability to fully straighten the knee and also fully flex the knee toward the chest. d In the seated position, the patient can selfpalpate the tibial tubercle, patellar tendon, and medial and lateral joint lines. If able to relax the quadriceps in knee extension, the patient can palpate patellar facets and medial and lateral femoral condyles. d The figure-4 position could be used to better delineate the lateral collateral ligament and assess for lateral collateral ligament tenderness. The COVID-19 pandemic and the need for social distancing has created challenges in health care access. Telemedicine has played an important role in the delivery of medical services and is likely to be of continued importance and use even after the current pandemic. This article provides the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine, which can be refined according to the capabilities of the patient and examiner. Supplemental material can be found online at: http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary Telemedicine technology and clinical applications Real-time video telemedicine applications in the emergency department: a scoping review of literature Personalized implementation of video telehealth Systematic review of telemedicine applications in emergency rooms Telehealth in physical medicine and rehabilitation: a narrative review How to conduct an outpatient telemedicine rehabilitation or prehabilitation visit Telemedicine in the era of COVID-19: the virtual orthopaedic examination The impact of musculoskeletal disorders on Americansdopportunities for action The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical setting Use of a modified treatmentbased classification system for subgrouping patients with low back pain: agreement between telerehabilitation and face-toface assessments Cervical radiculopathy and myelopathy: presentations in the hand A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy far as he or she can to the farthest position, which does not cause any discomfort. Evaluate the asymptomatic side for asymmetry. d Special tests B Intra-articular hip pathology: n FABER test, or figure-4 position, to address intra-articular hip pathology as well as provoke possible sacroiliac jointegenerated pain. n Active SLR sign indicative of pes planus or possible posterior tibialis tendon dysfunction. d Assess active ankle range of motion: Dorsiflexion, plantar flexion, inversion, and eversion; assess for reproduction of pain during any of these movements. d Gait: Assess gait mechanics and antalgic gait; toe walking, including repetitive toe raises, to assess Achilles, posterior tibialis, and plantar flexion strength; heel walking to assess anterior tibialis. d In an ambulatory child, in addition to the above, observe running, jumping, hopping on 1 foot, single leg stance, and so on.Special Tests d Strength: As able, the patient can assess ankle inversion and eversion strength against a stable immobilized object, such as a table or chair leg. d Thompson test in the kneeling position on the chair: the patient squeezes calf, and the examiner and patient observe for ankle plantar flexion. d Self-applied metatarsal squeeze: The patient squeezes the foot from both sides while pressing on the bottom of the foot between the third and fourth metatarsals to assess for pain reproduction or a clicking sound indicative of Mulder's sign. d In select patients, a hop test can be performed to assess for location of pain provocation.