Clinical skills - Soft Tissue Flashcards
Causes of pain in a leg
Anatomical structures involved e.g. skin, bursa, tendons, muscles, ligaments
Procceses that can cause pain
Injury
Infection
Inflammation
Insidious (Tumour)
Causes of leg pain - skin
Cellulitis Bruise Bites Burns Haemosiderin Ingrowing nails Ulcers
Cellulitis
infection of staph or strep in the skin (gram +ve cocci or rods), draw black line on skin to see whether spreading
What is haemosiderin related to
Varicose veins
Bursa definition
Potential space w/ epithelial lining
Produces SF which reduces friction and trauma
Usual cause of bursitis
Overactivity - helped w/ physio (self-limited)
Common types of bursitis
Trochaneteric bursitis
Prepatellar bursitis
Anserine bursitis
Retrocalcaneal bursitis
Why does trocahnetic bursitis usually present in women
Shorter legs
DIff pelvis
Can be retrocalcaneal bursitis be treated w steroids
No as there is no tendon sheath
Tenosynovitis
Infl of tendon sheath
Local or part of a systemic illness such as RhA
Enthesiitis
Infl of the entheses, the sites where tendons or ligaments insert into the bone
Degenerative tendon conditions
Overuse of Achilles
Adductor tendinitis - tear
Cause of leg pain - muscles
Overuse Viral infections e.g. flu Cramp Claudication Muscle rupture/ tear e.g. hamstrings Chronic pain e.g. fibromyalgia, myofascial pain syndromes Alcohol and other drugs e.g. statins Endocrine causes e.g. hypothyroidism Infl diseases of muscles e.g. polymyositis, PMR Compartment syndrome
Cause of claudication
Due to lack of blood flow
Main ligaments causing pain in the leg
MCL
LCL
Ankle ligaments - after injury points can be repositioned
Treatment of ligament pain
RICE
Analgesia
Physio
Grade I lateral ankle sprain
Stretching small tears
Grade II lateral ankle sprain
Larger, but incomplete tear
Grade III lateral ankle strain
Complete tear
Causes of leg pain - blood vessels
Veins -varicose, superficial thrombophlebitis, DVT
Arteries – aneurysm, atheroma, PVD (peripheral vascular disease)
Risk factors of DVT
Sticky blood - birth control, smokers Obesity Immobility Pregnancy Ortho pt – pelvic surgeries Varicose veins
Causes of leg pain - nerves
Referred e.g. sciatica
Peripheral neuropathy
Entrapment e.g. meralgia paraesthetica
Causes of leg pain - lymph
Lymphoedema
Approach to limb pain
History
Examination
Investigations
Management of the problem
Leg pain hx
Localisation and nature Duration Onset e.g. trauma Pain history Relieving and exacerbating history
Leg pain examination
Look how the pt moves
Look at how ill the pt is e.g. systemically unwell
Look at the area Feel for tenderness around the joint Move joint Get pt to move Check for numbness and weakness
Hernia
Weakness of abdominal wall so bowel pushes through
Shoulder exam - look
Positioning – undress (vest top), standing, space
Anteriorly, posteriorly, laterally:
Skin
Posture and symmetry
Bony structure – clavicle, sternoclavicular joint, acromioclavicular joint, acromion, acromion process, scapula
Joint swelling
Muscle bulk – supraspinatus, infraspinatus, deltoid
Shoulder exam - feel
Ask if it hurts? Standing behind pt: Sternoclavicular joint Clavicle Acromioclavicular joint Acromion Coracoid process Greater tuberosity Scapula: spine, medial border, inferior angle
External rotation pain of shoulder - ddx
Usually OA
High painful arc (shoulder) - ddx
Pain in acromioclavicular joint - subacromial bursitis
Mid painful arc (shoulder) - ddx
Pain in sub acromion space - sulbcromial bursitis
Shoulder exam - feel
Ask if it hurts? Standing behind pt: Sternoclavicular joint Clavicle Acromioclavicular joint Acromion Coracoid process Greater tuberosity Scapula: spine, medial border, inferior angle
Shoulder exam - move
Compare both sides
Flexion Extension Adduction Adduction Internal and external rotation
If any active movement is reduced, test passive movements
Abduction - shoulder exam
Ask pt to lift arm out to side
Normal is 90 degrees w/out scapula or 180 w/ scapula
Adduction - shoulder exam
Ask pt to move arm across front of body
Normal is 40 degrees
Pain in resisted shoulder movements
Infraspinatus (external rotation)
Subscapularis (internal rotation)
Supraspinatus (abduction)
Deltoid (abduction)
Causes of olecranon bursitis
Trauma
Rheumatoid
Gout
Elbow exam - look
Positioning – undress, seated, space Anteriorly, posteriorly, laterally Skin/ soft tissue – olecranon bursa/ nodules Bone Joint swelling Muscle bulk
Elbow exam - feel
Olecranon process Lateral epicondyle of humerus Medial epicondyle of humerus Ulna Head of radius
Elbow exam - move
Flexion - ask pt to bend elbow
Extension - ask pt to straighten
Ptonation
Supination
Elbow exam - pronation
Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces the floor
Elbow exam - supination
Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces upwards
Pain in resisted elbow movements
Flexion (biceps)
Extension (biceps)
Supination (supinator)
Pronation (pronator)
Wrist exam - look
Positioning, undress, space Dorsal and palmar aspects: Skin – colour, scars, bruising, nails Posture and symmetry Bony structures Joint swelling Muscle bulk
Wrist exam - feel
Ask if it hurts? Temperature/ tenderness Feel: Head of ulnar Its styloid process Radius base Its styloid process
Wrist exam - move
Flexion
Extension – prayer sign
Abduction (radial) – 20 degrees
Adduction (ulnar) – 50 degrees
Hand exam - look
Skin Muscle Joints Posture Nails
Hand exam - skin
Erythema, redness, scars
Hand exam - muscle
Wasting in dorsal aspects
Hand exam - joints
Ulnar deviation, Z thumbs, subluxation of wrist, boutonnieres, swan neck deformity
Hand exam - nails
Oncolysis, pitting (PsA)
Hand exam - feel
Bimanually - soft tissue (synovitis) or. bony Pisiform bone Scaphoid (in anatomical snuffbox) MCP squeeze MCP joints PIP joints DIP joints
Condns to recognise from examination
Carpal tunnel
Ulnar nerve entrapment
Medial nerve entrapment
Radial nerve entrapment
Hand exam - move (fingers)
MCPs – flexion/ extension
DIPs – flexion/ extension
PIPs – flexion/ extension
Abduction/ adduction of fingers
Hand exam - move (thumb)
Flexion Extension Abduction Adduction Opposition
Pain in restricted movements - hand
Opposition – T1 (median nerve)
Finger abductions – T1 (median nerve)
Wrist extension – C8, T1 (radial nerve)
Power – make a fist
Examination of nerve function
Motor component and sensory component
Masses can be …
Origination or acquired
Where could potential lumps and bumps come from
Skin Fat Connective Tissue Muscles Bones Joints Nerve Blood vessels Lymphatic system Organs Metastases
Types of acquired masses
Neoplastic
Infl
Infective
Infective masses
Rubor
Calor
Tumor
Dolor
Infl masses
Hx of infl condns e.g RhA etc Pain Tenderness Symmetry Other lesions
Benign neoplastic masses
A mass of cells that grows in an uncontrolled manner but does not have the ability to invade local structures or spread to other parts pf the body
Malignant neoplastic masses
A mass of cells that grows in an uncontrolled manner that has the ability to invade the local structures and has the ability to spread to other parts of the body. Also has the ability to kill the host is growth and spread is not controlled
Cancer
Name of benign neoplastic growths in skin
Papilloma
Name of benign neoplastic growths in fat
Lipoma
Name of benign neoplastic growths in bone
Osteotoma
Name of benign neoplastic growths in joints
Endochondroma
Name of benign neoplastic growths in organisms
Adenoma
Name of malignant neoplastic growths in skin
Squamous cell carcinoma
Name of malignant neoplastic growths in fat
Liposarcoma
Name of malignant neoplastic growths in bone
Osteosarcoma
Name of malignant neoplastic growths in joints
Chondrosarcoma
Name of malignant neoplastic growths in organs
Adenocarcinoma
Hx of masses - benign tumours
Slow rate of growth
Other long-term masses
Painless
Local pressure effects
Hx of masses - malignant tumours
Fast rate of growth Other new masses/ lesions Painful Local invasive effects Associated lumps Associated symptoms of metastasis/ systemic spread
Examination for lumps
Site
Size
Shape
Surface
Substance – consistency, soft, firm, hard
Surrounding structures – local tissue, lymph nodes, nerves, blood vessels, other organs
Examination findings - benign masses
Well defined Mobile Smooth Soft No associated masses
Examination findings - malignant masses
Ill defined Immobile Irregular Hard Associated masses Associated organomegaly Associated reduce function of muscle, nerve
Investigations that can be used for lumps and bumps
MRI
CT
Autopsy
Investigation findings - benign masses
Well defined
Capsule
No invasion
Homogenous signal pattern
Investigation findings - malignant masses
Ill defined No capsule Invasion of local tissue Heterogenous signal pattern Metastases in organs or lymph nodes
Significance of a bump having hard edges
Likely to be metastatic
Describing lumps and bumps
Position Colour Temp Shape/size/ surface Edge Consistency Fluctuation Translucency/ pulsability/ reducibility/ relation to other structures Bruits – noise Lymph node proximity
Mechanisms of soft tissue injury
Direct Injury
Long term wear and tear
Unclear? Infl
Repetitive injury
Examples of upper limb soft tissue injury
Shoulder ACI dislocation Shoulder dislocation Shoulder rotator cuff tear Long head of biceps tear Elbow dislocation Distal biceps tendon tear Skiers thumb Small joint dislocation Other ligament and tendon ruptures, flexor/ extensor tendons
Example of lower limb soft tissue injury
Knee ACL tear Knee collateral ligaments and menisci Quadriceps tendon rupture Patellar tendon rupture Tenoacchilles rupture Ankle sprain
Assessment of a soft tissue injury
HPC PMH Personal, social and occupation hx Examination Investigations Treatment
Clinical examination for soft tissue injury
Look for deformity/ signs of injury
Feel for tenderness, swelling
Move to assess,
Investigations of a soft tissue injury
X-rays
Ultrasound scan
CT scan (to investigate associated fracture)
MRI scan
Treatment for soft tissue injuries
Analgesia RICE Immobilise (splint, sling, brace) PT Surgical repair Education/ info
Treatment for acromioclavicular joint issues
Sling for 6 weeks
Physiotherapy
Surgery in severe cases
Must fix grades 4 & 5 injuries
Hook test
Poke finger in distal biceps tendon - test for distal bicep ruptures
Presentation of distal biceps rupture
Usually men in late 40s/ early 50s
Seen in bodybuilders as anabolic steroid makes tendons easier to tear
Struggle to supinate
Testing for ACL tear
Anterior draw test
Lachman’s test
MRI
Secondary condn associated with ACL tear
Post traumatic OA due to changed biomechanics of the knee
Clinical examination for Achilles Tendon rupture
Calf squeeze test and measure angle of declination
Treatment for Achilles Tendon Rupture
Walking boot for 3 months (tendons proximate)
Surgical repair
What does nerve compression result in
Ischaemia and demyelination of the nerve affecting its ability to conduct
Most common compression neuropathies in upper limb
Carpal tunnel syndrome
Cubital tunnel syndrome
Most common site of compression of peripheral nerves in lower limb
Common peroneal (fibular) nerve
Carpal tunnel
Complex of symptoms
Pain, numbness and tingling in the distribution of median nerve
Caused by compression within carpal tunnel
Affects 0.1 – 10% of pop
Risk factors for carpal tunnel syndrome
Traumatic (post wrist fracture/ lunate dislocation)
Pregnancy (common)
Hypothyroid (rare)
RhA (synovitis)
Chronic Renal Failure
Space occupying lesion (ganglion, tumour)
Who does carpal tunnel usually present in
Women 35-55
Typical symptoms and signs of carpal tunnel syndrome
Nocturnal dysesthesias
Paraesthesia on driving, using telephone, reading
Reduced dexterity (buttons, coins, sewing)
Thenar wasting – late sign, irreversible
Tests for carpal tunnel
Tinel’s
Phalen’s <60 secs
Flexion-compression – press on nerve and flex wrist, best test to use
The use of nerve conduction studies in compression neuropathies
Diagnostic uncertainty
Quantify degree of severity
Persistence of symptoms post CTD
Recurrence of symptoms post CTD
Ddx of carpal tunnel
C6 radiculopathy (get MRI)
Proximal site compression (rare) – flexor dystrophy syndrome, pronator syndrome
Non-organic/ non-anatomical cause
Non-operative treatment for carpal tunnel
Observation (may settle – e.g. pregnancy)
Splints (night symptoms)
Steroid injections
Steroid injection for carpal tunnel
Useful to confirm diagnosis
Injected in 30-degree angle, ulnar side of Palmaris Longus tendon
Surgery - carpal tunnel decompression
Performed under local anaesthetic (+/- tourniquet) – take 10 mins
Good at relieving pain, numbness recovery less consistent
Healing from carpal tunnel decompression
Performed under local anaesthetic (+/- tourniquet) – take 10 mins
Wound takes 2 weeks to heal
Most pts go back to work within 2-4 weeks
Expectation of outcome – depends on severity
Complications of surgery
Infection (rare) Bleeding and haematoma (rare) Scar pain/ tenderness – common/ last several weeks Pillar pain – may last several weeks Recurrence (<1%) Chronic Regional Pain Syndrome (rare) Incomplete relief of symptoms
Pillar pain
Pain over bony borders
Open vs endoscopic CTD
W/ endoscopic:
Quicker return to work
Higher rate nerve injury
Similarities in open and endoscopic CTD
No difference in symptomatic relief, revision rates and grip strength
Recurrent carpal tunnel
True recurrence <1%
Exclude other causes of symptoms e.g. double crush – C6 nerve root (MRI), peripheral neuropathy, consider Neurology
Re-operation about 70% successful
Non-structural cause
Cubital Tunnel syndrome
Ulnar nerve compression at the elbow
Ddx for cubital tunnel
Thoracic outlet syndrome
Pan coasts tumour
C8/ T1 radiculopathy
Symptoms of cubital tunnel
Postural – leaning on elbow/ night symptoms
Established compression – numbness and weakness
Signs of cubital tunnel syndrome
Altered sensation – ulnar side of ring finger and pinky Wartenberg Wasting first dorsal interosseous Clawing – hyperextension of DIP Froments Tinel’s at epicondyle
Investigations for cubital tunnel
NCS
X-ray - look for elbow arthritis
Non-operative treatment for cubital tunnel
Postural advice
Nocturnal splints
Surgery consideration
Surgery consideration in any numbness/ weakness and +ve NCS
Surgical indications for cubital tunnel
Failure of non-operative management
Motor weakness/ loss sensation
Types of nerve damage
Neurotmesis
Neuropraxia
Axonotmesis
Neurotmesis
Complete disruption of never and sheath, chronic
Neuropraxia
Transient nerve dysfunction, no damage to nerve or sheath, will recover fully
Axonotmesis
Disruption of axon but Schwann cell myelin sheath intact, recovery could occur if insulting force removed in timely fashion
Associated condns. w/ carpal tunnel
Diabetes mellitus Hypothyroidism Rheumatoid arthritis Pregnancy Acromegaly Trauma e.g. wrist fracture
Common causes of bursitis
Repetitive motion or position Injury Trauma Inflammatory arthritis Gout Infection
Epidemiology of bursitis
Equal incidence in males and females
Immunocompromised, diabetic, rheumatoid, alcoholism and HIV patients are at greater risk of septic bursitis
Presentation of bursitis
Sudden inability to move the joint Swelling Redness Bruising Rash Sharp or shooting pain Fever
Investigations for bursitis
X-ray cannot identify bursitis, however ican rule out other conditions Physical examination
Ultrasound or MRI when diagnosis cannot be done through physical examination alone
Management of bursitis
Medication - abx if infection
Injections
Assistive walking aid
Surgery - drainage or removed if necessary
Prognosis of bursitis
Not a fatal disorder, with most patients having a good outcome
Pts who don’t avoid the causative mechanism will be more likely to develop recurrence
Fibromyalgia
Long-term condition that causes pain all over the body
Disorder of sensory processing of non-nociceptive input.
What causes FM to occur
Sensitisation of the CNS, as a result of abnormal temporal summation, altered pain thresholds, increased substance P levels, and blood flow abnormalities in pain processing centres in the brain
Presentation of FM
Increased Sensitivity to Pain Extreme Tiredness (fatigue) Muscle Stiffness Paraesthaesia Difficulty Sleeping Cognitive Problems Headaches Irritable Bowel Syndrome (IBS) Anxiety and Depression Cold Hands Hair Loss Allodynia
Epidemiology of FM
The prevalence of fibromyalgia is estimated at 2-5%
7x more common in women than men
Prevalence increases with age and peaks in the 50s and 60s.
Causes of FM
Unknown but could be: Genetics Trauma Giving Birth Surgery Infection Psychological Factors (such as bereavement) Also strong link with deopression
Dx of FM
Usually be based on the symptoms in the patient history and you may also examine the patient for tender points
Potential complications of FM
Extreme allodynia with high levels of distress. Opioid or alcohol dependence. Marked functional impairment. Severe depression and anxiety. Obesity and physical deconditioning. Metabolic syndrome.
Allodynia
Pain felt in response to non-painful stimuli
Presentation of chronic fatigue syndrome
Chronic fatigue lasting longer than six months that is NOT alleviated by rest
Muscle pains and aches
Problems with thinking or memory (brain frog)
Frequent headaches
Joint pain
Post-exertional malaise (PEM)
Pts symptoms become worse after physical/mental activity that previously would not have been an issue with them
Can lead to worse symptoms and longer recovery time
Often associated with headaches, dizziness, and extreme fatigue
Some causes of myopathy
Vit D deficiency Diabetes Thyrotoxicosis Cushing's disease HIV
Causes of muscle pain
Chronic compartment syndrome Viral infections Anaerobic conditions Sprains/ trauma Cramps CTDs e.g. lupus, myositis Fibromyalgia Toxins e.g. drugs Metabolic e.g. hypothyroidism
Preventing DVT
LMWH (prophylactic) Stockings Exercise Aspirin Stop smoking Keep calf pump contracting
DVT presentation
Leg is very swollen
Presentation of arterial thrombosis
Leg is pale, pulseless, cold
Medical emergency
Signs that there is a metastasis
Lymphadenopathy
Treatment for Ruptured Achilles tendon
Equinus cast (similar to plaster of Paris)
