(16) Musculoskeletal Tables

Question 1

Rheumatoid Arthritis: Process

Answer 1

Chronic inflammation
of synovial membranes
with secondary
erosion of adjacent
cartilage and
bone, and damage
to ligaments and
tendons

Question 2

Rheumatoid Arthritis: Common Locations

Answer 2

Hands—initially
small joints (PIP
and MCP joints),
feet (MTP joints),
wrists, knees, elbows,
ankles

Question 3

Rheumatoid Arthritis: Pattern of Spread

Answer 3

Symmetrically additive:
progresses to
other joints while
persisting in initial
joints

Question 4

Rheumatoid Arthritis: Onset

Answer 4

Usually insidious;
human leukocyte
antigen (HLA) and
non-HLA genes account
for >50% of
risk of disease; involves
proinflammatory
cytokines

Question 5

Rheumatoid Arthritis: Progression and Duration

Answer 5

Often chronic (in
>50%), with remissions
and exacerbations

Question 6

Rheumatoid Arthritis: Associated Symptoms

Answer 6

Swelling: Frequent swelling of synovial
tissue in joints or tendon sheaths; also subcutaneous nodules

Redness, Warmth, and tenderness: Tender, often warm, but seldom red

Stiffness: Prominent, often for an hour or more in the mornings, also after inactivity

Limitation of Motion: Often develops; affected by associated joint contractures
and subluxation, bursitis, and tendinopathy

Generalized Symptoms: Weakness, fatigue,
weight loss, and low fever are common

Question 7

Osteoarthritis (Degenerative Joint Disease) Common Locations

Answer 7

Knees, hips, hands
(distal, sometimes
PIP joints), cervical
and lumbar spine,
and wrists (first carpometacarpal
joint);
also joints previously
injured or
diseased

Question 8

Osteoarthritis (Degenerative Joint Disease) Pattern of Spread

Answer 8

Additive; however,
may involve only
one joint

Question 9

Osteoarthritis (Degenerative Joint Disease) Onset

Answer 9

Usually insidious;
genetics may account
for >50% of
risk of disease; repetitive
injury and
obesity increase risk

Question 10

Osteoarthritis (Degenerative Joint Disease) Progression and Duration

Answer 10

Slowly progressive,
with temporary exacerbations
after
periods of overuse

Question 11

Acute Gout: Process

Answer 11

An inflammatory
reaction to microcrystals
of monosodium
urate

Question 12

Osteoarthritis (Degenerative Joint Disease) Associated Symptoms

Answer 12

Swelling: Small joint effusions may
be present, especially in
the knees; also bony enlargement

Redness, warmth, and tenderness: Possibly tender, seldom
warm, and rarely red.
Inflammation may accompany
disease flares
and progression

Stiffness: Frequent but brief (usually
5–10 min), in the
morning and after inactivity

Limitation of Motion: often develops

Generalized Symptoms: usually absent

Question 13

Acute Gout: Pattern of Spread

Answer 13

Early attacks usually
confined to one
joint

Question 14

Acute Gout: Onset

Answer 14

Sudden; often at
night; often after injury,
surgery, fasting,
or excessive
food or alcohol
intake

Question 15

Acute Gout: Progression and Duration

Answer 15

Occasional isolated attacks
lasting days up
to 2 wks; they may get
more frequent and severe,
with persisting
symptoms

Question 16

Chronic Tophaceous Gout: Process

Answer 16

Multiple local accumulations
of sodium
urate in the joints
and other tissues
(tophi), with or without
inflammation

Question 17

Chronic Tophaceous Gout: Common Locations

Answer 17

Feet, ankles, wrists,

fingers, and elbows

Question 18

Acute Gout: Associated Symptoms

Answer 18

Swelling: Present, within and
around the involved joint,
usually in men (have
higher serum urate levels);
often polyarticular
later in course

Redness, warmth, and tenderness: Exquisitely tender, hot,
and red

Stiffness: not evident

Limitation of Motion: Motion is limited primarily
by pain

Generalized Symptoms: Fever may be present;
also consider also septic
arthritis

Question 19

Chronic Tophaceous Gout: Onset

Answer 19

Gradual development
of chronicity
with repeated attacks

Question 20

Chronic Tophaceous Gout: Progression and Duration

Answer 20

Chronic symptoms

with acute exacerbations

Question 21

Polymyalgia Rheumatica: Process

Answer 21

A disease of unclear
etiology in people
older than age 50
yrs, especially
women; overlaps
with giant cell arteritis

Question 22

Polymyalgia Rheumatica: Common Locations

Answer 22

Muscles of the hip,
shoulder girdle, and
neck; symmetric

Question 23

Polymyalgia Rheumatica: Onset

Answer 23

Insidious or abrupt,
even appearing
overnight

Question 24

Chronic Tophaceous Gout: Associated Symptoms

Answer 24

Swelling: Present as tophi in joints,
bursae, and subcutaneous
tissues; check ears and
extensor surfaces for
tophi

Redness, warmth, and tenderness: Tenderness, warmth,
and redness may be
present during exacerbations

Stiffness: present

Limitation of Motion: present

Generalized Symptoms: Possibly fever; patients
may also develop renal
failure and renal stones

Question 25

Polymyalgia Rheumatica: Associated Symptoms

Answer 25

Swelling: Swelling and edema may
be present over dorsum
of hands, wrists, feet

Redness, warmth, and tenderness: Muscles often tender,
but not warm or red

Stiffness: Prominent, especially in
the morning

Limitation of Motion: Pain restricts movement,
especially in
shoulders

Generalized Symptoms: Malaise, depression, anorexia,
weight loss, and
fever, but no true weakness

Question 26

Fibromyalgia Syndrome: Process

Answer 26

Widespread musculoskeletal
pain and
tender points. Central
pain sensitivity
syndrome that may
involve aberrant
pain signaling and
amplification

Question 27

Fibromyalgia Syndrome: Common Locations

Answer 27

Multiple specific
and symmetric “tender
points,” often
unrecognized until
examined; especially
in the neck, shoulders,
hands, low
back, and knees

Question 28

Fibromyalgia Syndrome: Pattern of Spread

Answer 28

Shifts unpredictably
or worsens in response
to immobility,
excessive use, or
exposure to cold

Question 29

Fibromyalgia Syndrome: Onset

Answer 29

Variable

Question 30

Fibromyalgia Syndrome: Progression and Duration

Answer 30

Chronic, with “ups

and downs

Question 31

Fibromyalgia Syndrome: Associated Symptoms

Answer 31

Swelling: none

Redness, warmth, and tenderness: Multiple specific and
symmetric tender “trigger
points,” often not
recognized until the
examination

Stiffness: Present, especially in
the morning—often confused with inflammatory conditions

Limitation of Motion: Absent, though stiffness is greater at the extremes of movement

Generalized Symptoms: Sleep disturbance, usually with fatigue on awakening; overlaps
with depression and other pain syndromes

Question 32

Mechanical Neck Pain: Patterns

Answer 32

Aching pain in the cervical
paraspinal muscles and ligaments
with associated muscle spasm and
stiffness and tightness in the upper
back and shoulder, lasting up to 6
wks. No associated radiation,
paresthesias, or weakness.
Headache may be present.

Question 33

Mechanical Neck Pain: Possible Causes

Answer 33

Mechanism poorly understood, possibly
sustained muscle contraction. Associated
with poor posture, stress, poor sleep, poor
head position during activities such as
computer use, watching television, and
driving.

Question 34

Mechanical Neck Pain: Physical Signs

Answer 34

Local muscle tenderness, pain on
movement. No neurologic deficits. Possible
trigger points in fibromyalgia. Torticollis if
prolonged abnormal neck posture and
muscle spasm

Question 35

Mechanical Neck Pain - Whiplash: Patterns

Answer 35

Mechanical neck pain with aching
paracervical pain and stiffness,
often beginning the day after injury.
Occipital headache, dizziness,
malaise, and fatigue may be
present. Chronic whiplash
syndrome if symptoms last more
than 6 mo; occurs in 20%–40% of
injuries.

Question 36

Mechanical Neck Pain - Whiplash: Possible Causes

Answer 36

Musculoligamentous sprain or strain from
forced hyperflexion—hyperextension
injury to the neck, as in rear-end collisions

Question 37

Mechanical Neck Pain - Whiplash: Physical Signs

Answer 37

Localized paracervical tenderness,
decreased neck range of motion, perceived
weakness of the upper extremities. Causes
of cervical cord compression such as
fracture, herniation, head injury, or altered
consciousness are excluded.

Question 38

Cervical Radiculopathy from Nerve Root Compression: Patterns

Answer 38

Sharp burning or tingling pain in
the neck and one arm, with
associated paresthesias and
weakness. Sensory symptoms often
in myotomal pattern, deep in
muscle, rather than dermatomal
pattern.

Question 39

Cervical Radiculopathy from Nerve Root Compression: Possible Causes

Answer 39

Dysfunction of cervical spinal nerve,
nerve roots, or both from foraminal
encroachment of the spinal nerve (∼75%),
herniated cervical disc (∼25%). Rarely
from tumor, syrinx, or multiple sclerosis.
Mechanisms may involve hypoxia of the
nerve root and dorsal ganglion and release
of inflammatory mediators.

Question 40

Cervical Radiculopathy from Nerve Root Compression: Physical Signs

Answer 40

C7 nerve root affected most often (45–60%),
with weakness in triceps and finger flexors
and extensors. C6 nerve root involvement
also common, with weakness in biceps,
brachioradialis, wrist extensors.

Question 41

Cervical Radiculopathy from Cervical Cord Compression: Process

Answer 41

Neck pain with bilateral weakness
and paresthesias in both upper and
lower extremities, often with
urinary frequency. Hand
clumsiness, palmar paresthesias,
and gait changes may be subtle.
Neck flexion often exacerbates
symptoms.

Question 42

Cervical Radiculopathy from Cervical Cord Compression: Possible Causes

Answer 42

Usually from cervical spondylosis, defined
as cervical degenerative disc disease from
spurs, protrusion of ligamentum flavum,
and/or disc herniation (∼80%); also from
cervical stenosis from osteophytes,
ossification of ligamentum flavum, and RA.
Large central or paracentral disc herniation
may also compress cord.

Question 43

Cervical Radiculopathy from Cervical Cord Compression: Physical Signs

Answer 43

Hyperreflexia; clonus at the wrist, knee, or
ankle; extensor plantar reflexes (positive
Babinski signs); and gait disturbances. May
also see Lhermitte sign: neck flexion with
resulting sensation of electrical shock
radiating down the spine. Confirmation of
cervical myelopathy warrants neck
immobilization and neurosurgical
evaluation.

Question 44

Mechanical Low Back Pain: Patterns

Answer 44

Aching pain in the lumbosacral area; may radiate
into lower leg, especially in L5 (lateral leg) or S1
(posterior leg) dermatomes. Signifies anatomic or
functional abnormality in absence of neoplastic,
infectious, or inflammatory disease. Usually
acute (<3 mo), idiopathic, benign, and selflimiting;
represents 97% of symptomatic low
back pain. Commonly work related and
occurring in patients 30–50 yrs. Risk factors
include heavy lifting, poor conditioning, obesity

Question 45

Mechanical Low Back Pain: Possible Causes

Answer 45

Often arises from muscle and ligament
injuries (∼70%) or age-related
intervertebral disc or facet disease (∼4%).
Causes also include herniated disc (∼4%),
spinal stenosis (∼3%), compression
fractures (∼4%), and spondylolisthesis
(2%).

Question 46

Mechanical Low Back Pain: Physical Signs

Answer 46

Paraspinal muscle or facet tenderness,
pain with back movement, loss of
normal lumbar lordosis; motor,
sensory, and reflex findings are
normal. In osteoporosis, check for
thoracic kyphosis, percussion
tenderness over a spinous process, or
fractures in the thoracic spine or hip

Question 47

Sciatica (Radicular Low Back Pain): Patterns

Answer 47

Shooting pain below the knee, commonly into
the lateral leg (L5) or posterior calf (S1);
typically accompanies low back pain, often with
associated paresthesias and weakness. Bending,
sneezing, coughing, straining during bowel
movements can worsen the pain

Question 48

Sciatica (Radicular Low Back Pain): Possible Causes

Answer 48

Sciatic pain is sensitive, ∼95%, and specific,
∼88%, for disc herniation. Usually from
herniated intervertebral disc with
compression or traction of nerve root(s) in
people ages 50 yrs or older. L5 and S1 roots
are involved in ∼95% of disc herniations; root
or spinal cord compression from neoplastic
conditions in fewer than 1% of cases. Tumor
or midline disc herniation may cause bowel
or bladder dysfunction, leg weakness from
cauda equina syndrome (S2–S4).

Question 49

Sciatica (Radicular Low Back Pain): Physical Signs

Answer 49

Disc herniation most likely if calf
wasting, weak ankle dorsiflexion,
absent ankle jerk, positive crossed
straight-leg raise (pain in affected leg
when healthy leg tested); negative
straight-leg raise makes diagnosis
highly unlikely. Ipsilateral straight-leg
raise sensitive, about 65–98%, but not
specific, about 10–60%.

Question 50

Lumbar Spinal Stenosis: Patterns

Answer 50

Neurogenic claudication with gluteal and/or
lower extremity pain and/or fatigue that may
occur with or without back pain. Pain is
provoked by lumbar extension (as in walking
uphill) due to reduced space in the lumbar spine
from degenerative changes in the spinal canal.
Positive LR is >6.0 if pain is absent when seated,
improved with bending forward, or present in
both buttocks and legs. Positive LR is <4.0 if gait
is wide-based and Romberg test is abnormal.

Question 51

Lumbar Spinal Stenosis: Possible Causes

Answer 51

Arises from hypertrophic degenerative
disease of one or more vertebral facets and
thickening of the ligamentum flavum,
causing narrowing of the spinal canal
centrally or in lateral recesses. More
common after age 60 yrs.

Question 52

Lumbar Spinal Stenosis: Physical Signs

Answer 52

Posture may be flexed forward to
reduce symptoms, with lower
extremity weakness and hyporeflexia.
Thigh pain typically occurs after 30 s
of lumbar extension. Straight-leg raise
is usually negative.

Question 53

Chronic Back Stiffness: Possible Causes

Answer 53

Ankylosing spondylitis, an inflammatory
polyarthritis, most common in men
younger than 40 yrs. Diffuse idiopathic
hyperostosis (DISH) affects men more than
women, usually age ≥50 yrs.

Question 54

Nocturnal Back Pain, Unrelieved by Rest: Possible Causes

Answer 54

Consider metastatic malignancy to the
spine from cancer of the prostate, breast,
lung, thyroid, and kidney, and multiple
myeloma.

Question 55

Nocturnal Back Pain, Unrelieved by Rest: Physical Signs

Answer 55

Loss of the normal lumbar lordosis,
muscle spasm, limited anterior and
lateral flexion. Lateral immobility of the
spine, especially in thoracic area improves
with exercise.

Question 56

Low Back Pain Referred from the Abdomen or Pelvis: Patterns

Answer 56

Usually a deep, aching pain; the level varies
with the source. Accounts for ∼2% of low back
pain.

Question 57

Low Back Pain Referred from the Abdomen or Pelvis: Possible Causes

Answer 57

Peptic ulcer, pancreatitis, pancreatic
cancer, chronic prostatitis, endometriosis,
dissecting aortic aneurysm, retroperitoneal
tumor, and other causes.

Question 58

Low Back Pain Referred from the Abdomen or Pelvis: Physical Signs

Answer 58

Variable with the source. Local
vertebral tenderness may be present.
Spinal movements are not painful and
range of motion is not affected. Look
for signs of the primary disorder.

Question 59

Rotator Cuff Tendinitis (Impingement Syndrome)

Answer 59

Repeated shoulder motion, for example, from throwing or
swimming, can cause edema and hemorrhage followed by
inflammation, most commonly involving the supraspinatus tendon.
Acute, recurrent, or chronic pain may result, often aggravated by
activity. Patients report sharp catches of pain, grating, and weakness
when lifting the arm overhead. When the supraspinatus tendon is
involved, tenderness is maximal just below the tip of the acromion. In
older adults, bone spurs on the undersurface of the acromion may
contribute to symptoms.

Question 60

Rotator Cuff Tears

Answer 60

The rotator cuff muscles and tendons compress the humeral head
into the concave glenoid fossa and strengthen arm movement—the
subscapularis in internal rotation, the supraspinatus in elevation, and
the infraspinatus and teres minor in external rotation. Injury from a
fall, trauma, or repeated impingement against the acromion and the
coracoacromial ligament may cause a partial- or full-thickness tear of
the rotator cuff, the most common clinical problem of the shoulder,
especially in older patients. Patients complain of chronic shoulder
pain, night pain, or catching and grating when raising the arm
overhead. Weakness or tears of the tendons usually start in the
supraspinatus tendon and progress posteriorly and anteriorly. Look
for atrophy of the deltoid, supraspinatus, or infraspinatus muscles.
Palpate anteriorly over the anterior greater tuberosity of the humerus
to check for a defect in muscle attachment and below the acromion
for crepitus during arm rotation. In a complete tear, active abduction
and forward flexion at the glenohumeral joint are severely impaired,
producing a characteristic shrug of the shoulder and a positive “drop
arm” test (see p. 655).

Question 61

Calcific Tendinitis

Answer 61

Calcific tendinitis is a degenerative process in the tendon associated
with the deposition of calcium salts that usually involves the
supraspinatus tendon. Acute disabling attacks of shoulder pain may
occur, usually in patients ages ≥30 yrs, especially in women. The arm
is held close to the side, and all motions are severely limited by pain.
Tenderness is maximal below the tip of the acromion. The subacromial
bursa, which overlies the supraspinatus tendon, may be inflamed.
Chronic less severe pain may also occur.

Question 62

Bicipital Tendinitis

Answer 62

Inflammation of the long head of the biceps tendon and tendon
sheath causes anterior shoulder pain resembling and often coexisting
with rotator cuff tendinitis. Both conditions may involve
impingement injury. Tenderness is maximal in the bicipital groove.
Externally rotate and abduct the arm to separate this area from the
subacromial tenderness of supraspinatus tendinitis. With the patient’s
arm at the side, elbow flexed to 90°, ask the patient to supinate the
forearm against your resistance. Increased pain in the bicipital groove
confirms this condition. Pain during resisted forward flexion of the
shoulder with the elbow extended is also characteristic.

Question 63

Adhesive Capsulitis (Frozen Shoulder)

Answer 63

Adhesive capsulitis refers to fibrosis of the glenohumeral joint
capsule, manifested by diffuse, dull, aching pain in the shoulder and
progressive restriction of active and passive range of motion, especially in
external rotation, with localized tenderness. The condition is usually
unilateral and occurs in people ages 40–60 yrs. There is often an
antecedent disorder of the shoulder or another condition (such as
myocardial infarction) that has decreased shoulder movements.
The disorder may take 6 mo to 2 yrs to resolve. Stretching exercises
may help.

Question 64

Acromioclavicular Arthritis

Answer 64

Acromioclavicular arthritis is relatively common, usually arising from
prior direct injury to the shoulder girdle with resulting degenerative
changes. Tenderness is localized over the acromioclavicular joint. Patients
report pain with movements of the scapula and arm abduction

Question 65

Anterior Dislocation of the Humerus

Answer 65

Shoulder instability from anterior subluxation or dislocation of the
humerus usually results from a fall or forceful throwing motion, then
can become common unless treated or the precipitating motion is
avoided. The shoulder seems to “slip out of the joint” when the arm
is abducted and externally rotated, causing a positive apprehension sign
for anterior instability when the examiner places the arm in this
position. Any shoulder movement may cause pain, and patients hold
the arm in a neutral position. The rounded lateral aspect of the
shoulder appears flattened. Dislocations may also be inferior,
posterior (relatively rare), and multidirectional.

Question 66

Olecranon Bursitis

Answer 66

Swelling and inflammation of the olecranon bursa may result from trauma,
gout, or rheumatoid arthritis (RA). The swelling is superficial to the
olecranon process and may reach 6 cm in diameter. Consider aspiration for
both diagnosis and symptomatic relief.

Question 67

Rheumatoid Nodules

Answer 67

Subcutaneous nodules may develop at pressure points along the extensor
surface of the ulna in patients with RA or acute rheumatic fever. They are
firm and nontender. They are not attached to the overlying skin but may be
attached to the underlying periosteum. They can develop in the area of the
olecranon bursa, but often occur more distally.

Question 68

Arthritis of the Elbow

Answer 68

Synovial inflammation or fluid is felt best in the grooves between the
olecranon process and the epicondyles on either side. Palpate for a boggy,
soft, or fluctuant swelling and for tenderness. Causes include RA, gout and
pseudogout, osteoarthritis, and trauma. Patients report pain, stiffness, and
restricted motion.

Question 69

Epicondylitis

Answer 69

Lateral epicondylitis (tennis elbow) follows repetitive extension of the wrist or
pronation–supination of the forearm. Pain and tenderness develop 1 cm distal to
the lateral epicondyle and possibly in the extensor muscles close to it. When
the patient tries to extend the wrist against resistance, pain increases.
Medial epicondylitis (pitcher’s, golfer’s, or Little League elbow) follows
repetitive wrist flexion such as throwing. Tenderness is maximal just lateral and
distal to the medial epicondyle. Wrist flexion against resistance increases the
pain.

Question 70

Hands: Acute Rheumatoid Arthritis

Answer 70

Tender, painful, stiff joints in RA, usually with
symmetric involvement on both sides of the
body. The distal interphalangeal (DIP),
metacarpophalangeal (MCP), and wrist joints are
the most frequently affected. Note the fusiform
or spindle-shaped swelling of the PIP joints in
acute disease.

Question 71

Hands: Chronic Rheumatoid Arthritis

Answer 71

In chronic disease, note the swelling and
thickening of the MCP and PIP joints. Range of
motion becomes limited, and fingers may deviate
toward the ulnar side. The interosseous muscles
atrophy. The fingers may show “swan neck”
deformities (hyperextension of the PIP joints with
fixed flexion of the distal interphalangeal [DIP]
joints). Less common is a boutonnière deformity
(persistent flexion of the PIP joint with
hyperextension of the DIP joint). Rheumatoid
nodules are seen in the acute or the chronic stage.

Question 72

Hands: Osteoarthritis (Degenerative Joint Disease)

Answer 72

Heberden nodes on the dorsolateral aspects of the
DIP joints from bony overgrowth of OA. Usually
hard and painless, they affect middle-ages or
older adults; they are often associated with
arthritic changes in other joints. Flexion and
deviation deformities may develop. Bouchard
nodes on the PIP joints are less common. The
MCP joints are spared.

Question 73

Hands: Chronic Topaceous Gout

Answer 73

Urate crystal deposits, often with surrounding
inflammation, cause deformities in subcutaneous
tissues, bursae, cartilage, and subchondral bone
that mimic RA and OA. Joint involvement is
usually less symmetric than in RA. Acute
inflammation may be present. Knobby swellings
around the joints ulcerate and discharge white
chalk-like urates.

Question 74

Hands: Dupuytren Contracture

Answer 74

The first sign of a Dupuytren contracture is a thickened band overlying the flexor tendon
of the fourth finger and possibly the little finger near the distal palmar crease.
Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops
between the palm and finger. Finger extension is limited, but flexion is usually normal.
Flexion contracture of the fingers may gradually develop.

Question 75

Hands: Trigger Finger

Answer 75

Trigger finger is caused by a painless nodule in a flexor tendon in the palm, near the
metacarpal head. The nodule is too big to enter easily into the tendon sheath during
extension of the fingers from a flexed position. With extra effort or assistance, the finger
extends and flexes with a palpable and audible snap as the nodule pops into the tendon
sheath. Watch, listen, and palpate the nodule as the patient flexes and extends the fingers

Question 76

Hands: Thenar Atrophy

Answer 76

Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome (see
p. 664). Hypothenar atrophy suggests an ulnar nerve disorder.

Question 77

Hands: Ganglion

Answer 77

Ganglia are cystic, round, usually nontender swellings along tendon sheaths or joint
capsules, frequently at the dorsum of the wrist. The cyst contains synovial fluid arising
from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic
cavity. Flexion of the wrist makes ganglia more prominent; extension tends to obscure
them. Ganglia may also develop on the hands, wrists, ankles, and feet. They can
disappear spontaneously.

Question 78

Acute Tenosynovitis

Answer 78

Inflammation of the flexor tendon sheaths, acute tenosynovitis, may follow
local injury, overuse, or infection. Unlike arthritis, tenderness and swelling
develop not in the joint but along the course of the tendon sheath, from the
distal phalanx to the level of the metacarpophalangeal joint. The finger is held
in slight flexion; finger extension is very painful. Causative infectious agents
include Staphylococcus and Streptococcus species, disseminated gonorrhea, and
Candida albicans.

Question 79

Acute Tenosynovitis and Thenar Space Involvement

Answer 79

If the infection progresses, it may extend from the tendon sheath into the
adjacent fascial spaces within the palm. Infections of the index finger and
thenar space are illustrated. Early diagnosis and treatment are important.

Question 80

Felon

Answer 80

Injury to the fingertip may result in infection of the enclosed fascial spaces of
the distal pulp or phalanx pad of the fingertip, usually from Staphylococcus
aureus. Severe pain, localized tenderness, swelling, and dusky redness are
characteristics. Early diagnosis and treatment, usually incision and drainage,
are important for preventing abscess formation. If vesicles are present,
consider herpetic whitlow instead, usually seen in health care workers exposed
to herpes simplex virus in human saliva.

Question 81

Feet: Acute Gouty Arthritis

Answer 81

The metatarsophalangeal joint of the great toe is the initial site of attack in 50% of the
episodes of acute gouty arthritis. It is characterized by a very painful and tender, hot,
dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for a
cellulitis. The ankle, tarsal joints, and knee are also commonly involved.

Question 82

Flat Feet

Answer 82

Signs of flat feet may be apparent only when the patient stands, or they may become
permanent. The longitudinal arch flattens so that the sole approaches or touches the floor.
The normal concavity on the medial side of the foot becomes convex. Tenderness may be
present from the medial malleolus down along the medial plantar surface of the foot.
Swelling may develop anterior to the malleoli. Flat feet may be a normal variant or arise
from posterior tibial tendon dysfunction, seen in obesity, diabetes, and prior foot injury.
Inspect the shoes for excess wear on the inner sides of the soles and heels.

Question 83

Hallux Valgus

Answer 83

In hallux valgus, there is lateral deviation of the great toe and enlargement of the head of
the first metatarsal on its medial side, forming a bursa or bunion. This bursa may become
inflamed. Women are 10 times more likely to be affected than men.

Question 84

Morton Neuroma

Answer 84

Look for tenderness over the plantar surface between the third and fourth metatarsal
heads, from perineural fibrosis of the common digital nerve due to repetitive nerve
irritation (not a true neuroma). Check for pain radiating to the toes when you press on
the plantar interspace and squeeze the metatarsals with your other hand. Symptoms
include hyperesthesia, numbness, aching, and burning from the metatarsal heads into the
third and fourth toes.

Question 85

Ingrown Toenail

Answer 85

The sharp edge of a toenail may dig into
and injure the lateral nail fold, resulting
in inflammation and infection. A tender,
reddened, overhanging nail fold,
sometimes with granulation tissue and
purulent discharge, results. The great toe
is most often affected.

Question 86

Hammer Toe

Answer 86

Usually involving the second toe, a
hammer toe is characterized by hyperextension
at the metatarsophalangeal
joint with flexion at the proximal interphalangeal
(PIP) joint. A corn frequently
develops at the pressure point
over the PIP joint.

Question 87

Corn

Answer 87

A corn is a painful conical thickening of
skin that results from recurrent pressure
on normally thin skin. The apex of the
cone points inward and causes pain.
Corns characteristically occur over bony
prominences such as the fifth toe. When
located in moist areas such as pressure
points between the fourth and fifth toes,
they are called soft corns.

Question 88

Callus

Answer 88

Like a corn, a callus is an area of greatly
thickened skin that develops in a region
of recurrent pressure. Unlike a corn, a
callus involves skin that is normally
thick, such as the sole, and is usually
painless. If a callus is painful, suspect an
underlying plantar wart.

Question 89

Plantar Wart

Answer 89

A plantar wart is a hyperkeratotic lesion
caused by human papillomavirus, located
on the sole of the foot. It may look like
a callus. Look for the characteristic
small dark spots that give a stippled
appearance to a wart. Normal skin lines
stop at the wart’s edge. It is tender if
pinched side to side, whereas a callus is
tender to direct pressure.

Question 90

Neuropathic Ulcer

Answer 90

When pain sensation is diminished or
absent, as in diabetic neuropathy,
neuropathic ulcers may develop at
pressure points on the feet. Although
often deep, infected, and indolent, they
are painless. Underlying osteomyelitis
and amputation may ensue. Early
detection of loss of sensation using a
nylon filament is the standard of care in
diabetes.