(16) Musculoskeletal Reds Flashcards
Articular disease
typically involves:
- swelling and tenderness of the entire joint
- crepitus
- instability
- “locking”
- deformity
limits both active and passive ROM d/t stiffness or pain
Extra-articular disease
typically involves:
- point of focal tenderness in regions adjacent to articular structure
limits active ROM
rarely causes: swelling, instability, joint deformity
Pain in a single joint suggests:
- injury
- monoarticular arthritis
- extra-articular causes like tendonitis or bursitis
lateral hip pain w/ focal tenderness over the greater trochanter suggests ?
trochanteric bursitis
pattern of joint pain spread:
rheumatic fever vs rheumatoid arthritis
RF: migratory pattern
RA: additive and progressive w/ symmetric involvement
extra-articular joint pain occurs in:
inflammation of:
- bursae (bursitis)
- tendons (tendonitis)
- tendon sheaths (tenosynovitis)
sprains from stretching or tearing of ligaments
severe pain of rapid onset in a red swollen joint suggests ?
acute septic arthritis or crystalline arthritis (gout, CPPD)
- in kids consider osteomyelitis in a bone contiguous to a joint
Joint pain w/ butterfly (malar) rash =
systemic lupus erthythematous
Joint pain w/ Scaly plaques, especially on extensor surfaces, and pitted nails =
Psoriatic arthritis
Joint Pain w/ Heliotrope rash on the upper eyelid
Dermatomyositis
Joint Pain w/ Papules, pustules, or vesicles with reddened bases on the distal extremities
Gonococcal arthritis
Joint Pain w/ Expanding erythematous “target” or “bull’s eye” patch early in an illness
Lyme disease (erythema chronicum migrans)
Joint Pain w/ Painful subcutaneous nodules especially in pretibial area
Sarcoidosis, Behçet disease (erythema
nodosum)
Joint Pain w/ palpable purpura
vasculitis
Joint Pain w/ hives
serum sickness, drug reaction
Joint Pain w/ Erosions or scaling on the penis and crusted scaling papules on the soles and palms
Reactive (Reiter) arthritis (with urethritis, uveitis)
Joint Pain w/ The maculopapular rash of rubella
Arthritis of rubella
Joint Pain w/ Nailfold capillary changes
Dermatomyositis
systemic sclerosis
Joint Pain w/ Clubbing of the fingernails
Hypertrophic osteoarthropathy
Joint Pain w/Red, burning, and itchy eyes (conjunctivitis), eye pain and blurred vision (uveitis)
Reactive (Reiter) arthritis
Behçet syndrome
ankylosing spondylitis
Joint Pain w/ Scleritis
RA, IBD, vasculitis
Joint Pain w/ preceding sore throat
Acute rheumatic fever or gonococcal arthritis
Joint Pain w/ Oral ulcerations
RA (usually painless); Behçet disease
Joint Pain w/ Pneumonitis; interstitial lung disease
RA; systemic sclerosis
Joint Pain w/ Diarrhea, abdominal pain, cramping
IBD, reactive arthritis from Salmonella,
Shigella, Yersinia, Campylobacter;
scleroderma
Joint Pain w/ Urethritis
Reactive (Reiter) arthritis, gonococcal
arthritis
Joint Pain w/ Mental status change, facial or other weakness, stiff neck
Lyme disease with central nervous
system involvement
Maneuvers for Examining the Shoulder:
Acromioclavicular Joint
Crossover or crossed body adduction test.
- Adduct patient’s arm across the chest.
Pain with adduction is a positive test
Acromioclavicular joint tenderness and compression
tenderness have low LRs so are not diagnostically helpful
Maneuvers for Examining the Shoulder:
Overall Shoulder Rotation
Apley scratch test.
- Ask the patient to touch the opposite scapula using two motions
- tests abduction and external rotation
- tests adduction and internal rotation
Pain during these maneuvers suggests a rotator cuff disorder or adhesive capsulitis
Maneuvers for Examining the Shoulder:
Rotator Cuff (pain provocation tests)
Painful arc test
- Fully adduct the patient’s arm from 0° to 180
- Shoulder pain from 60° to 120° is a positive test for a subacromial impingement/rotator cuff tendinitis disorder
Neer impingement sign
- Press on the scapula to prevent scapular motion with one hand, and raise the patient’s arm with the other.
- This compresses the greater tuberosity of the humerus against the acromion.
- Pain during this maneuver is a positive test for a subacromial impingement/rotator cuff tendinitis disorder
Hawkins impingement sign
- Flex the patient’s shoulder and elbow to 90° with the palm facing down
- with one hand on the forearm and one on the arm, rotate the arm internally
- This compresses the greater tuberosity against the
supraspinatus tendon and coracoacromial ligament.
- Pain during this maneuver is a positive test for supraspinatus impingement/rotator cuff tendinitis
Maneuvers for Examining the Shoulder: Strength Tests
External rotation lag test
- With the patient’s arm flexed to 90° with palm up, rotate the arm into full external rotation
- Inability of the patient to maintain external rotation is a positive test for supraspinatus and infraspinatus disorders
Internal rotation lag test
- Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°
- Then you lift the hand off the back, which further internally rotates the shoulder
- Ask the patient to keep the hand in this position
- 90º flexion
- Inability of the patient to hold the hand in this position is positive test for a subscapularis disorder
Drop-arm test
- Ask the patient to fully abduct the arm to shoulder
level, up to 90°, and lower it slowly
- Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle.
- Weakness during this maneuver is a positive test for a supraspinatus rotator cuff tear or bicipital tendinitis
Maneuvers for Examining the Shoulder:
Composite Tests
External rotation resistance test. Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pressure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation. - Pain or weakness during this maneuver is a positive test for an infraspinatus disorder, with a positive LR of 2.6 and negative LR of 0.49. Limited external rotation points to glenohumeral disease or adhesive capsulitis
Empty can test. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms. - Inability of the patient to hold the arm fully abducted at shoulder level or control lowering the arm is a positive test for a suprasinatus rotator cuff tear, with a positive LR of 1.3.
articular joint pain
- decreased active and passive ROM
- morning stiffness or “gelling”
nonarticular joint pain
- periarticular tenderness
- only passive ROM remains intact
Severe pain of rapid onset in a red
swollen joint suggests
- acute septic arthritis
- crystalline arthritis (gout; CPPD)
In children, consider osteomyelitis
in a bone contiguous to a joint
Inflammatory joint disorders have many
causes:
- infectious (Neisseria gonorrhoeae
or Mycobacterium tuberculosis) - crystal-induced (gout, pseudogout)
- immune-related (RA, systemic lupus erythematous)
- reactive (rheumatic fever, reactive arthritis)
- idiopathic.
In noninflammatory joint disorders,
consider ?
- trauma (rotator cuff tear),\
- repetitive use (bursitis, tendinitis)
- degenerative changes (OA)
- fibromyalgia
Joint inflammation with fever and chills is
seen in ?
- septic arthritis
- also consider crystalline arthritis
Morning joint stiffness that gradually
improves with activity is more common
in ?
intermittent stiffness & gelling are seen in ?
inflammatory disorders like RA
and PMR
OA
Monoarticular arthritis can be:
traumatic, crystalline, or septic
Oligoarticular arthritis occurs in:
infection from gonorrhea or rheumatic fever, connective tissue disease, and OA
Polyarthritis may be:
viral or inflammatory from RA, SLE, or psoriasis
Joint involvement is usually symmetric in:
asymmetric in:
.
symmetric:
RA
SLE
ankylosing spondylitis
asymmetric:
psoriatic, reactive (Reiter), and IBD-associated arthritis.
Joints: Constitutional symptoms are common
in:
RA, SLE, PMR, and other inflammatory arthritides
High fever and chills suggest an infectious cause.
Leukemia & joints
can infiltrate the synovium;
chemotherapy can also cause joint
pain
2 ways to assess for C spine injury:
The NEXUS criteria are normal alertness, no posterior midline cervical spine tenderness, no focal neurologic deficits, no evidence of intoxication, and no painful distracting injury.
The Canadian C-Spine Rule includes age,
mechanism of injury, low risk factors
allowing assessment of range of
motion, and testing of neck rotation.
Radicular pain signals
spinal nerve compression and/or irritation, most commonly at C7 or C6. Unlike low back pain, the principal cause is foraminal impingement from degenerative joint changes (70% to 75%), rather than disc herniation (20% to 25%).
Nonspecific low back pain is usually from
musculoligamentous injuries
and age-related degenerative processes of the intervertebral discs and facet joints
For midline back pain, diagnoses include:
For pain off the midline,
assess for:
musculoligamentous injury;
disc herniation; vertebral collapse; spinal cord metastases; and, rarely, epidural abscess.
assess:
muscle strain, sacroiliitis,
trochanteric bursitis, sciatica, and hip arthritis as well as for renal conditions like pyelonephritis or stones
Sciatica
radicular gluteal and posterior
leg pain in the S1 distribution that increases with cough or Valsalva
- 85% of cases are associated
with a disc disorder, usually at L4–L5 or L5–S1
- Leg pain that resolves with
rest and/or lumbar forward flexion occurs in spinal stenosis
Consider cauda equina syndrome from
an S2–S4 midline disc or tumor if
there is bowel or bladder dysfunction (usually urinary retention with overflow incontinence), especially if there is saddle anesthesia or perineal numbness. Pursue immediate imaging and surgical evaluation
In cases of low back pain plus another indicator, there is a pretest probability
of
serious systemic disease of ∼10%.
low back pain “yellow flags”
Ask about anxiety, depression,
and work stress. Assess any maladaptive
coping, inappropriate fears or
beliefs, or tendency to somatization
Bone mass peaks by:
age 30
Bone loss from age-related declines in
estrogen and testosterone is initially
rapid, then slows and becomes continuous
A previous low-impact fracture from standing height or lower is the greatest risk factor for
subsequent fracture
Once injured, articular cartilage is replaced by
less resilient fibrocartilage, increasing risk of pain and OA
Acute involvement of only one joint
suggests
trauma, septic arthritis, or
crystalline arthritis.
(RA is typically polyarticular and symmetrical)
Malalignment occurs in
Dupuytren contracture
bow-legs (genu varum)
knock-knees (genu valgum)
Look for:
subcutaneous nodules in ?
effusion in ?
crepitus over inflamed joints in ?
RA or rheumatic fever
trauma
OA or over the inflamed tendon sheaths of tenosynovitis
Decreased range of motion is present in ?
Anterior cruciate ligament (ACL) laxity occurs in ?
arthritis, joints with tissue inflammation or surrounding fibrosis, or bony fixation (ankylosis)
knee trauma; muscle atrophy and weakness is seen in RA
Palpable bogginess or doughiness of the synovial membrane indicates ?
Palpable joint fluid is present in ?
synovitis, which is often accompanied by effusion
effusion, tenderness over the tendon sheaths in tendinitis
Increased warmth is seen in
arthritis
tendinitis
bursitis
osteomyelitis
Redness over a tender joint suggests
septic or crystalline arthritis, or possibly
RA.
Diffuse tenderness and warmth over a
thickened synovium suggest ?
focal tenderness suggests ?
arthritis or infection
injury and trauma
Facial asymmetry is seen in ?
TMJ disorders
(a category of orofacial pain with multifactorial etiologies; typically, there is unilateral chronic pain with chewing, jaw clenching, or teeth grinding, often associated with stress and accompanied by headache)
Swelling, tenderness, and decreased
range of motion signal
TMJ inflammation
or arthritis.
TMJ dislocation can be caused by
trauma
Palpable crepitus or clicking is present in
poor occlusion, meniscus injury, or synovial swelling from trauma
In TMJ syndrome, there is pain and
tenderness with palpation.
a
This muscular meshwork can make it
difficult to distinguish shoulder from
neck disorders.
646
? may cause elevation of one
shoulder.
With ? of the shoulder, the rounded lateral aspect of the shoulder appears flattened
Scoliosis
anterior dislocation
Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear within 2 to 3 weeks of a rotator cuff tear; infraspinatus atrophy has a positive likelihood ratio (LR) of 2 for rotator cuff disease
a
Swelling from synovial fluid accumulation is rare and must be significant before the glenohumeral joint capsule appears distended. Swelling in the acromioclavicular joint is easier to detect as the joint is more superficial
a
Localized tenderness points to subacromial or subdeltoid bursitis, degenerative changes, or calcific deposits in the rotator cuff. Swelling suggests a bursal tear that communicates with the articular cavity.
a
Tenderness over the SITS muscle insertions and inability to abduct the arm above shoulder level occurs in sprains, tears, and tendon rupture of the rotator cuff, most commonly the supraspinatus
a
Tenderness and effusion suggest glenohumeral
joint synovitis. If the margins
of the capsule and synovial membrane
are palpable, a moderate to large effusion
is present; minimal synovitis cannot
be detected on palpation.
a
Restricted range of motion occurs in
bursitis, capsulitis, rotator cuff tears or
sprains, and tendinitis
a
test pure glenohumeral motion:
test scapulothoracic motion:
The final 30° tests: combined glenohumeral and scapulothoracic
motion.
patient should raise the arms to shoulder level at 90°, with palms facing down
patient should turn the palms up and raise the arms an additional 60°
combined glenohumeral and scapulothoracic motion
An age of ≥60 years and a positive
drop-arm test are the findings most
likely to identify a degenerative rotator
cuff tear, with positive LRs of 3.2
and 2.9 to 5.0, respectively. The combined
findings of supraspinatus weakness,
infraspinatus weakness, and a
positive impingement sign increase
the LR of a tear to 48.0; when all three
are absent, the LR falls to 0.02, virtually
ruling out the diagnosis.
a
Swelling over the olecranon process is
suspicious for olecranon bursitis (see
p. 702); inflammation or synovial fluid
suggests arthritis
a
Tenderness distal to the epicondyle is common in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (pitcher’s or golfer’s elbow).
a
After injury, preservation of active range of motion and full elbow extension makes fracture highly unlikely. Full elbow extension has a sensitivity of 84% to >98% and specificity of 48% to >97% for absence of fracture.62,63 Tenderness over the radial head, olecranon, or medial epicondyle and bruising, plus absent elbow extension, may improve these test characteristics.64 Full elbow extension also makes intra-articular effusion or hemarthrosis unlikely
a
Degenerative changes at the first carpometacarpal
joint of the thumb are
more common in women
a
Guarded movement suggests injury.
Flexor tendon damage causes abnormal
finger alignment
a
Diffuse swelling is common in arthritis or
infection; local swelling suggests a ganglion.
Laceration, puncture, injection
marks, burn, or erythema result from
trauma.
a
Heberden nodes (DIP joints) and Bouchard nodes (PIP joints) are common findings in OA. In RA, inspect for symmetric deformity in the PIP, MCP, and wrist joints; later, there is MCP subluxation and ulnar deviation
a
Thenar atrophy occurs in
in ulnar nerve compression, there is
median nerve compression from carpal tunnel syndrome
hypothenar atrophy
Dupuytren flexion contractures in the third, ring, and fifth fingers, arise from thickening of the palmar fascia (see p. 704). Trigger digits are caused by stenosing tenosynovitis
a
Tenderness over the distal radius after a fall is suspicious for:
Bony step-offs also suggest:
Colles fracture
fracture
In RA, there is persisting bilateral
swelling and/or tenderness
a
Tenderness over the extensor and
abductor tendons of the thumb at the
radial styloid occurs in de Quervain
tenosynovitis and gonococcal tenosynovitis.
a
“Snuffbox” tenderness with the wrist in ulnar deviation and pain at the scaphoid tubercle are suspicious for:
Poor blood supply increases risk of:
occult scaphoid fracture (a common injury)
scaphoid bone avascular necrosis
The MCPs are often boggy or tender
in RA, but are rarely involved in OA.
Pain with compression also occurs in
posttraumatic arthritis.
a
There are PIP changes in RA; Bouchard
nodes in OA. Pain at the base of the
thumb occurs in carpometacarpal
arthritis.
a
Hard dorsolateral nodules on the DIP
joints, or Heberden nodes are common in
the DIP joints are also involved in
OA
psoriatic arthritis
Tenderness and swelling occur in tenosynovitis, or inflammation of the tendon sheaths. De Quervain tenosynovitis involves the extensor and abductor tendons of the thumb as they cross the radial styloid.
a
Arthritis, tenosynovitis, and Dupuytren
contracture all impair range of motion
a
Forceful repetitive handwork with wrist flexion such as keyboarding or mail sorting, vibration, cold environments, wrist anatomy, pregnancy, RA, diabetes, and hypothyroidism are risk factors for carpal tunnel syndrome
a
Decreased sensation in the median nerve territory is a common sign of carpal tunnel syndrome (sensitivity to pinprick and two-point discrimination <50%; specificity >85%; positive LR of hypalgesia is 3.1).
a
Decreased grip strength is a positive test for weakness of the finger flexors and/or intrinsic muscles of the hand. It also results from inflammatory or degenerative arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy. Grip weakness plus wrist pain are often present in de Quervain tenosynovitis.
a
Weakness on thumb abduction is a
positive test. The abductor pollicis
longus is innervated only by the
median nerve
a
Combined use of a hand symptom diagram, median nerve territory hypalgesia, and thumb abduction weakness are most consistent with nerve conduction diagnoses of carpal tunnel syndrome
a
Aching and numbness in the median
nerve distribution is a positive test
(sensitivity 23% to 60%; specificity
64% to 91%; LR ≤1.5)
a
Numbness and tingling in the median nerve distribution within 60 seconds is a positive test (sensitivity 10% to 91%; specificity 33% to 86%; LR ≤1.5).68
a
Tinel and Phalen signs do not reliably
predict positive electrodiagnosis of
carpal tunnel disease
a
Inspect for impaired hand movement
in
arthritis
trigger finger
Dupuytren contracture
Neck stiffness signals arthritis, muscle
strain, or other underlying pathology
that should be pursued; headache may
be present.
a
Lateral deviation and rotation of the
head are seen in torticollis, from contraction
of the sternocleidomastoid
muscle.
a
Vertebral tenderness raises concerns
for fracture, dislocation, underlying
infection, or arthritis
a
Tenderness occurs in arthritis, especially
at the facet joints between C5
and C6.
a
Step-offs occur in spondylolisthesis,
or forward slippage of one vertebra,
which may compress the spinal cord
a
Tenderness over the sacroiliac joint is
common in sacroiliitis and ankylosing
spondylitis
a
Pain with percussion occurs in vertebral
osteoporotic fractures, infection,
and malignancy
a
Increased thoracic kyphosis occurs
with aging
a
In scoliosis, lateral and rotatory curvature of the spine brings the head back to midline. Scoliosis often becomes evident during adolescence, before symptoms appear
a
Unequal shoulder heights occur in scoliosis, the Sprengel deformity of the scapula from the attachment of an extra bone or band between the upper scapula and C7, “winging” of the scapula from loss of long thoracic nerve innervation to the serratus anterior muscle, and contralateral weakness of the trapezius
a
Unequal heights of the iliac crests, or pelvic tilt, occur in unequal leg lengths, scoliosis, and hip abduction or adduction. Check if unequal leg lengths disappear when a block is placed under the shorter limb. “Listing” of the trunk to one side is seen with a herniated lumbar disc
a
Birthmarks, port-wine stains, hairy
patches, and lipomas often overlie
bony defects such as spina bifida
a
Café-au-lait spots (discolored patches
of skin), skin tags, and fibrous tumors
are common in neurofibromatosis
a
Spasm occurs in degenerative and
inflammatory muscle disorders, overuse,
prolonged contraction from
abnormal posture, and anxiety
a
Sciatic nerve tenderness is seen with a
herniated disc or nerve root impingement
from a mass lesion.
a
Herniated intervertebral discs, most common at L5–S1 or L4–L5, may cause tenderness of the spinous processes, intervertebral joints, paravertebral muscles, sacrosciatic notch, and sciatic nerve
a
Limited range of motion is caused by
stiffness from arthritis, pain from
trauma, overuse, and muscle spasm
from torticollis
a
Assess any complaints or findings of
neck, shoulder, or arm pain, numbness,
or weakness for possible cervical
cord or nerve root compression
a
Tenderness at C1–C2 in RA is suspicious
for possible subluxation and high cervical
cord compression and warrants
prompt additional assessment
a
Deformity of the thorax on forward
bending, especially when the height
of the scapulae is unequal, suggests
scoliosis
a
Persistence of lumbar lordosis suggests
muscle spasm or ankylosing
spondylitis
a
Decreased spinal mobility is common
in OA and ankylosing spondylitis
a
Consider lumbosacral cord or nerve
root compression; arthritis, mass
lesion, or infection in the hip, rectum,
or pelvis may also cause symptoms.
a
Most hip problems appear during the
weight-bearing stance phase
a
A wide base suggests cerebellar disease or foot problems. Pain during weight bearing or examiner strike on the heel occurs in femoral neck stress fractures
a
Hip dislocation, arthritis, unequal leg
lengths, or abductor weakness can
cause the pelvis to drop on the opposite
side, producing a waddling gait
a
Lack of knee flexion, which makes the leg functionally longer, interrupts the smooth pattern of gait, causing circumduction (swinging the leg out to the side
a
Loss of lordosis occurs with paravertebral
spasm; excess lordosis suggests a
flexion deformity of the hip
a
Disparities in leg length occur in abduction or adduction deformities and scoliosis. Leg shortening and external rotation are common in hip fracture
a
Sacroiliac joint tenderness suggests ?
sacroiliitis
Bulges along the ligament suggest
an inguinal hernia or, at times, an
aneurysm
a
Enlarged lymph nodes point to infection
in the pelvis or lower extremity
a
Causes of groin tenderness are
synovitis of the hip joint, arthritis; bursitis; or
possible psoas abscess.
Focal tenderness over the trochanter confirms
Tenderness over the posterolateral surface of the greater trochanter occurs in
trochanteric bursitis
localized tendinitis, muscle spasm from referred hip pain, and iliotibial band tendinitis.
Intra-articular causes include OA, osteonecrosis of the femoral head, acetabular labral tears, and femoral neck stress fracture. Extra-articular causes include trochanteric bursitis, muscle strain, sacroiliac disorders, and lumbar radiculopathy
??
Look for tenderness in ischiogluteal bursitis or “weaver’s bottom”; because of the adjacent sciatic nerve, this may
mimic
sciatica
In flexion deformity of the hip, as the opposite hip is ?
the affected hip:
flexed (with the thigh against the chest)
does not allow full hip extension and the affected thigh appears flexed
Flexion deformity may be masked by an increase, rather than flattening, in
lumbar lordosis and an anterior pelvic tilt
Restricted abduction and internal and external rotation are common in
hip OA
Pain with maximal flexion and adduction and internal rotation or with abduction and external rotation with
full extension signals
acetabular labral tear
Problems with patellar tracking, for example, in patients with shallower grooves, especially women, can lead to
arthritis, anterior knee pain, and
patellar dislocation
In women, quadriceps contraction often exerts a more lateral pull (Q angle) that alters patellar tracking, contributing to
anterior knee pain
Stumbling or “giving way” of the knee during heel strike suggests
quadriceps weakness or abnormal patellar tracking
Quadriceps atrophy signals
hip girdle weakness in older adults
Swelling over the patella occurs in ?
Swelling over the tibial tubercle suggests ? or, if more medial, ?
prepatellar bursitis (housemaid’s knee)
infrapatellar bursitis; anserine bursitis
Bony enlargement at the joint margins, genu varum deformity, and stiffness lasting ≤30 minutes are typical findings in ?. Crepitus is also common.
OA
A ? with joint line point tenderness is common after
trauma and requires prompt further evaluation.
medial meniscus tear
MCL tenderness after injury is suspicious for
an MCL tear
- LCL injuries are less frequent
Tenderness over the tendon or inability to extend the knee suggests
partial or complete tear of the patellar tendon
Pain with compression and patellar
movement during quadriceps contraction
occurs in ?
Two of three findings are most diagnostic
of the patellofemoral pain
syndrome:
chondromalacia
- pain with quadriceps contraction; pain with squatting
- pain with palpation of the posteromedial/ or lateral patellar border
Swelling around the patella points to
synovial thickening or effusion of the knee joint
Thickening, bogginess, or warmth occurs with (joints)
synovitis and nontender effusions from OA
? is triggered by excessive kneeling
? from running, valgus knee deformity,
or OA
? from distention of the gastrocnemius semimembranosus bursa from underlying arthritis or trauma
Prepatellar bursitis
anserine bursitis
popliteal or “Baker” cyst
A fluid wave or bulge on the medial side between the patella and the femur is a positive test for
effusion
A palpable fluid wave is a positive test or “balloon sign.” A palpable returning fluid wave into the suprapatellar pouch
further confirms
a major effusion, present in knee fractures
A palpable fluid wave returning into the pouch is also a positive test for
major effusion
A defect in the muscles, tenderness, and swelling signal a ?
Tenderness and thickening of the tendon, at times with a protuberant posterolateral bony process of the calcaneus, suggests ?
ruptured Achilles tendon
Achilles tendinitis
Absent plantar flexion is a positive test for ?
Achilles tendon rupture
- Sudden severe pain “like a gunshot,” an ecchymosis from the calf into the heel, and a flat-footed gait with absent “toe-off” may also be present
Crepitus with flexion and extension signals
patellofemoral OA, a probable precursor of knee OA
ACL tears are notably more frequent in ?, attributed to ?
women
ligamentous laxity related to estrogen cycling and
to differences in anatomy and neuromuscular control
A palpable click or pop along the medial or lateral joint line is a positive test for
a tear of the posterior portion of the medial meniscus
- The tear may displace meniscal tissue, causing “locking” on full knee extension
Pain or a gap in the medial joint line is a positive test for
an MCL injury
Pain or a gap in the lateral joint line points is a positive test for
LCL injury (less common than MCL injuries)
A few degrees of forward movement
are normal if equally present on the
opposite side.
690
A forward jerk showing the contours
of the upper tibia is a positive test, or
anterior drawer sign, with a positive LR
of 11.5 for an ACL tear
690
ACL injuries result from knee hyperextension,
direct blows to the knee, and
twisting or landing on an extended
hip or knee
690
Significant forward excursion is a positive
test for an ACL tear (positive LR
of 17.0).
690
If the proximal tibia falls back, this is a
positive test for PCL injury (positive LR
of 97.8).
690
Isolated PCL tears are less common,
usually resulting from a direct blow to
the proximal tibia.
690
Localized tenderness is often present in
arthritis
ligamentous injury
infection
Check for rheumatoid nodules and tenderness, commonly found in
Achilles tendinitis, bursitis, or partial tear from trauma
Focal heel tenderness at the attachment site of the plantar fascia is typical of ?
risk factors are:
plantar fasciitis
anatomic (overpronation, flat feet)
improper footwear
excessive use
overtraining with prolonged heel-strike exercise
Presence or absence of a heel spur does not change the diagnosis.
Most ankle sprains involve
foot inversion and injury to the weaker lateral ligaments (anterior talofibular and
calcaneofibular), with overlying tenderness, swelling, and ecchymosis
After trauma, pain in the malleolar zone plus either bone tenderness over the posterior aspects of either malleolus
(or over the navicular or base of the fifth metatarsal) or an inability to bear weight for four steps is suspicious
for
ankle fracture and warrants radiography (known as the Ottawa ankle and foot rules)
Tenderness on compression is an early sign of ?
Acute inflammation of the first MTP joint is common in ?
RA
gout
Tenderness along the posterior medial malleolus is seen in
posterior tibial tendinitis.
Pain and tenderness, called metatarsalgia,
occurs in
trauma
arthritis
vascular compromise
Tenderness over the third and fourth metatarsal heads on the plantar surface is suspicious for
Morton neuroma
Forefoot abnormalities like hallux valgus, metatarsalgia, and Morton neuroma are more common with
wear of high heeled shoes with narrow toe boxes.
Pain during movements of the ankle and the foot helps to localize possible
arthritis
An arthritic joint frequently causes pain when ?, whereas
a ligamentous sprain produces pain when ?.
moved in any direction
the ligament is stretched
For example, often, ankle sprain inversion with plantar flexion of the foot causes pain, whereas eversion with plantar flexion is relatively pain free
Pain suggests ?
Instability occurs in?
acute synovitis
chronic synovitis and claw-toe deformity.
Measured leg length is the same in
scoliosis
Pain with chewing also occurs in
TMJ disorders
trigeminal neuralgia
temporal arteritis
