Knee (Ottawa)
knee pain plus ANY of following –> Sn 1.00,Sp 0.49 >55yo, TTP @ head of fibula OR patella , can’t flex 90deg; no NWB 4 steps
Knee (Pittsburgh)
Blunt trauma or fall plus Sn = .99, Sp = .60 <12yo, >50yo, inability to walk 4 steps
Ottawa Ankle and Foot rules
Sn 1.0, Sp 0.4
Pain in malleolar zone (ankle) / midfoot zone (foot) AND any one of following:
1) Bone tenderness at posterior edge OR tip of distal tibia/fibula (ankle)
2) base 5th MT OR navicular (foot)
3) Unable to bear weight for 4 steps immediately after injury and during exam
Canadian C-spine rules
Level II (validated in RCT) 1.0 Sn, (.98-1.0) Sp.42 Alert (GCS = 15 and stable trauma) Any high risk factors (ANY yes = X-ray)? • >65yo OR • dangerous MOI Fall >1m, axial load to head, MVC >60mph, rollover, collision, motorized rec vehicle, bicycle collision OR • Paresthesias in extremities Any low risk factor (any yes = safe assessment of ROM) • Simple rear-end MVC? • Sitting position in ED? • Ambulatory any time? • Delayed onset neck pain? • Absence midline C-spine tenderness? ANY yes => Actively rotate 45deg bilat? (no = Xray) ALL “no” = Xray
Hip OA
Cluster #1: Hip pain, IR<15, Flexion<115 OR ESR < 45 mm/hr Sn .86 Sp = .75 Cluster #2: Hip pain w/IR, age > 50, AM stiffness 60 min -LR .19 +LR 3.4
Knee OA
Knee pain and 3/6: Sn.95 Sp.69 age>50; stiff<30min; crepitus; bony tenderness; bony enlargement; no warmth +LR 3.1 -LR 0.1
LumboPelvic Manip CPR
Cleland
5 conditions: 4/5 Sp .92, +LR 13.2
- FABQ-W<19,
- Sx NOT distal to knee
- one Hip IR > 35
- lumbar hypomobility
with these 2 conditions: +LR 12.8
- ONLY <16 days AND no sx distal to knee
BUT…only 10% of patients met the CPR
Wainner Radiculopathy CPR
- Positive Spurling test
- Positive neck distraction test
- Positive upper-limb tension test (A-med)
- < 60° cervical rotation to involved side 4 pos
4/4 positive = +LR 30.3; Sp.99 Sn.24
3/4 positive = +LR 6.1
Laslett SI Joint
Distraction, Thigh thrust, Gaenslens (x2), Compression, Sacral Thrust
3 / 6 + = Sn. 91, Sp .81 +LR 6.9, -LR .12
Location: L5 (or above) UNILATERAL AND NOT CENTRAL NOT DISCOGENIC (b/c no central/peripheralization)
–> remove false positives RULE IN SI joint (Force, position, hand placement)
–> remove false negative
Nexus II CT s/p head injury
Level II Sn .98 (95% CI .97-.99) If NO factors present:
- evidence of significant skull fx
- scalp hematoma
- neurolgic deficit
- altered elve of alertness
- abnormal behavior
- coagulopathy
- persistent vomiting
- age > 65
Nexus C-spine rules
Sn. 90.7 (85-94) C-spine indicated for patients with trauma unless ALL five are true:
- No cervical mid-line tenderness
- No evidence of intoxication
- Normal levels of alertness
- No focal neurological deficit
- No painful distracting injuries
Cleland Thoracic Thrust Manipulation CPR
5/6 = 100% of 3 Thoracic manipulations giving 1 week improvement
- Sxs < 30 days
- No sxs distal to shoulder
- Sxs not worse with looking up
- Cx extension <30deg
- FABQ < 12
- diminished T3-T5 kyphosis
Hicks stabilization CPR
3/4 –> 50% improvement in disability (with coordination/stability exercises)
- Age < 40
- PIT test
- aberrant movment
- SLR > 91
Tseng Cervical Manip CPR
CPR for immediate improvement in either pain, satisfaction, or perception of condition
- <11.5 NDI
- Bilateral involvement pattern
- NOT sedentary work > 5hrs / day
- feel better moving neck
- cervical extension = not worse
- spondylosis without radic
>= 4/6factors 60% to 90% chance of immediate improvement
Raney Traction Cervical CPR
- Peripheralization with C4-C7 mobility testing
- Positive shoulder ABD sign
- age >= 55
- +ULTT (median)
- sxs decrease with distraction
3/5 +LR 4.81
4/5 +LR 11.7
Serious Spinal Conditions DDX
(list)
- cancer
- infection
- cauda equina
- spinal fracture
Spinal Fracture CPR
- Female
- Age > 70
- Trauma (major in young, minor in elderly)
- Corticosteroid
1 positive = Sn .88, Sp .50 +LR 1.8
2 positive = Sn .63, Sp .96, +LR 15.5
3 positive = Sn .38, Sp 1.00 +LR 218
Meniscal CPR
- hx mechanical catching/locking
- joint line tenderness
- pain w/ forced knee hyperextension
- pain w/ maximum passive knee flexion
- pain/audible click with McMurray
5/5 –> Sn .11 Sp .99 +LR 11.2, -LR .90
4/5 –> Sn .16 Sp .96 +LR 4.3 -LR .87
for medial: JLT (rules in / out)
for lateral: Thessaly at 5o (rules out) + JLT (rules in)
Puentedura et al 2012 Cervical manip
- <38 days
- positive expectation for cervical manip
- side to side difff in cervical ROT ROM >10 deg
- pain with PA of middle cervical spine
