3 physical exam pearls for patients with pain

One of my favorite and most valued physical exam findings is the Carnett sign, of which it seems not many physicians are aware. This is an excellent tool in assessing patients' reports of abdominal pain. Most often the elicitation of a report of abdominal pain or eliciting of tenderness on abdominal exam leads almost immediately to a CT scan searching for pathology of the abdominal viscera. The Carnett sign is invaluable in helping the clinician determine if abdominal imaging is actually needed.

In this maneuver, the physician asks the supine patient to tense their abdominal musculature, usually by elevating the straight legs like a leg lift or by lifting the head off the bed. Then, the clinician palpates the area of pain or tenderness. If the pain or tenderness is unchanged or accentuated, it very likely means that the pain emanates not from the abdominal cavity, but from the abdominal musculature. This is usually due to myofascial pain from exercise, trauma, or malpositioning. It can occasionally be due to an abdominal wall hernia or abdominal wall hematoma, or occasionally a radiculitis. It almost invariably means that imaging of the intra-abdominal viscera is not indicated. A negative test, wherein the patient's pain improves with the forced muscular contraction, strongly suggests an intra-abdominal process for which imaging should be seriously entertained. If more of us performed this simple maneuver, I suspect we would order far fewer imaging tests in the office, urgent care, and ED.

Another clinical pearl that I have found frequently useful and which dramatically reduces hip and or spine imaging and orthopedic referrals is related to palpating the region of the greater trochanter. Hip pain and buttock pain are tremendously common in internal medicine practice. In fact, I have had several patients scheduled for either lumbar spinal decompressive surgery or hip replacement surgery, and upon their preoperative medical evaluation we find that they may not need surgery, just a trochanteric bursa steroid injection.

For the patient reporting hip pain, buttock pain, or lateral thigh pain, it is essential that the clinician roll the supine patient onto his/her unaffected side and then identify the area of the protuberance of the greater trochanter. Then very firm pressure needs to be applied in a straight downward fashion toward the bed. Many patients will then yelp, stating something along the lines of, “Yes, that's the spot, please stop.” Regardless of the degree of osteoarthritis on the hip film or the lumbar foraminal stenosis on the MRI, with this positive finding there is a great likelihood that the real culprit of the pain is inflammation of the greater trochanteric bursa. Intrabursal steroids, transdermal NSAIDs, or heat may make a dramatic difference, sparing the patient from surgery.

One more physical exam pearl is frequently overlooked. We frequently examine where the patient describes pain, and often not in the surrounding area. Medial knee pain is a very common symptom in an internal medicine physician's office. Patients frequently have joint line tenderness and crepitance associated with this. This often results in radiography revealing the presence of moderate to severe osteoarthritic changes in the knee joint, even if sometimes there is no abnormality. This results in standard treatment of osteoarthritis of the knee and frequently referral to orthopedics for consideration of intra-articular steroid injection and sometimes total knee arthroplasty.

What is occasionally left behind is the failure to discover where the pain truly stems from. While palpating the knee joint line is common, as is testing for ligamentous laxity or meniscal tearing, it is uncommon for physicians to palpate below the joint line. For many patients who report pain, primarily in the medial knee region, the locus of pain can be found approximately 2 to 3 inches inferior to the joint line, just inferior to the medial prominence of the tibial medial condyle. Patients may exhibit exquisite tenderness here, strongly suggesting that their primary pathology is not osteoarthritis, but rather pes anserine bursitis. Again, heat, physical therapy, transdermal NSAIDs, or bursal steroid injection are likely to solve the problem.