ECOS 1 Final Clinical Flashcards
AC Separation
step off at the acromioclavicular joint- seen in x ray
Somatic dysfunction: Superior AC Joint somatic dysfunction
Resists/Direct Barrier: inferior pressure to distal clavicle
AC vs SC joint glide
AC joint likes to posteriorly glide while the SC joint moves anteriorly glide
The most sensitive and specific test for shoulder impingement is
painful arc
When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or “impinge” on) the tendon and the bursa, causing irritation and pain
Painful Arc Test:
Patient abducts arm starting at their side.
(+) Test: Pain is elicited within 60 and 120 degrees of shoulder abduction.
Indicates sub acromial impingement and /or rotator cuff injury.
What is the most sensitive indicator of joint disease?
ROM
Rotator Cuff Tear
most common cause of shoulder pain
Painful Arc Test
Patient abducts arm starting at their side.
(+) Test: Pain is elicited within 60 and 120 degrees of shoulder abduction.
Highest positive LR of all Rotator cuff maneuvers
Lowest Negative LR of all rotator cuff maneuvers
Indicates sub acromial impingement and /or rotator cuff injury
Reflex grading scale
0- reflex absent
1- somewhat diminished, low normal
2- average, normal,
3- brisker than average, possibly but not necessarily indicative of disease
4- very brisk, hyperactive, with clonus
Lateral Epicondylitis
pain with resisted wrist extension with elbow in full extension
+ test = pain/tenderness around lateral epicondyle
Radial Head Dysfunction
fall prone = posterior radial head glide
fall supine = anterior radial head glide
Ex: patient fell prone-
so posterior radial head, in MET physician will place patient forearm in supination, patient will try to pronate
Medial Epicondylitis
Pain with resisted wrist flexion with elbow in full extension
+ test = pain/tenderness around the medial epicondyle
Phalen’s sign
special test: wrist
place dorsal aspects of the patient’s hands together and force in wrist flexion. Hold for 60 seconds.
+test= any reproduction of symptoms paresthesia in the distribution of the median nerve (supplies thumb, index finger, and middle fingers on palmar aspect AND top 1/3 of index finger and middle finger on dorsal aspect)
indication: carpal tunnel syndrome
Deep Tendon Reflexes for UE/Dermatomes
bicep: C5-6
tricep: C6-7
brachioradialis: C5-6
tricep, thumb: C6-7
lateral forearm: C6
medial forearm: C8
nipples: T4
umbilicus: T10
Cervical Spondylosis
refers to degenerative changes of the spine- degenerative discs and osteophytes
most common cause of acute and chronic neck pain in adults. chances of getting it increases with age
it can generate general neck pain, radiculopathy, and myelopathy
Meningitis
fever, headache, photophobia, neck pain
positive Brudzinski’s sign
can DEFINITIVELY diagnose with lumbar puncture
Contraindication to HVLA
A. Anticoagulants/arthritis B. Bones- osteoporosis/disruption C. Carotid/PVD disease/risks D. Down syndrome L. Local Metastases, Ligament disruption
Spina Bifida
Spine and spinal cord don’t form properly. It’s a type of neural tube defect.
Risk factors:
- -FmHx of neural tube defects
- -Folate Deficiency
- -Diabetes
- -Increased body temperature
- -Obesity
- -Medications
Spina bifida occulta: “Occulta” means hidden. It’s the mildest and most common type.
Meningocele: a sac of fluid comes through an opening in the baby’s back & protrusion of meningitis. No nerves protrude.
Myelomeningocele: the most severe type. Protrusion & spinal canal is open along several vertebrae in the lower or middle back. The membranes and spinal nerves push through this opening, exposing tissues and nerves. Life-threatening infections, may lead to paralysis and bladder and bowel dysfunction.
Scoliosis
Lateral curve of the spine greater than 10 degrees with vertebral rotation.
Classification: Congenital, Neuromuscular, or Idiopathic (85% are idiopathic)
- -Adolescent Idiopathic Scoliosis (AIS) is MC form. Doesn’t progress, don’t need to screen.
- —> AIS evaluation is based on angle of trunk rotation (ATR)>7°and Cobb angle >10°
Risk factors: 2-4% of adolescents. M=F to have minor scoliosis (~10°) However, F more likely to progress to severe disease.
If both parents have AIS, kids are 50Xs more likely to require treatment than the general population.
Variable accuracy of Adam’s Forward Bend Test. Bend & find spinal rotation and rib hump.
PE: shoulder height difference, posterior scapula, leg lengths equal. Dextrose is MC (right sided curve, right shoulder higher, creases on left)
Scoliosis progress tracked by Risser sign (amount of calcification present in the iliac apophysis and measures the progressive ossification from anterolaterally to posteromedially. Increased grade with progression)
Red Flags
- -Onset before age 8
- -Severe pain
- -Rapid curve progression >1 degree per month
- -Unusual Left thoracic curve (convex to the left) –MC is dextrose.
- —> Left is associated with neurological defects, abnormal reflexes, numbness, paresthesia, spinal cord tumors
- -Neurological deficits or findings –midline hairy patch (spina bifida), etc.
Lower Back Pain (LBP)
MC reason for doctor’s visit
5th most common reason for all physician visits
Onset at 20-40 y/o
Can be self-limited, resolve with little intervention.
Acute LBP: 6 to 12 weeks of pain b/t the costal angles and gluteal folds that may radiate down one or both legs (sciatica). Nonspecific and no definite cause.
common causes of low back pain:
Cauda Equina Syndrome, short leg syndrome, psoas syndrome, back sprain/sprain
Compression Fractures
Vertebrae can collapse (shorter in height), fragments affect spinal cord & nerves, decreasing blood & O2 to spinal cord
Elderly white females (pain worse with flexion, going supine to sitting, & sitting to standing)
Age, prolonged use of steroids, hx of osteoporosis
Trauma, post-menopause, having one fracture puts you at risk for more, osteoporosis
Diagnosis: Weak: Vertebral tenderness, limited spine range of motion
Herniated Nucleus Pulposus
Aka a herniated (also called bulged, slipped, or ruptured) disc: part of the disc is pushed out of the annulus into spinal canal
Arm or leg pain, numbness or tingling, weakness.
Pain originates from the lumbar spine and radiate down the leg into the foot “sciatica”
Sharp burning pain -electric quality
Weakness in affected myotome(decreased reflexes), decreased sensation to affected dermatome
Causes: Obesity, occupation, genetics, smoking.
diagnosed by MRI
Spine structures cause Sacroiliac joint pain (pain to the thigh)
Lumbar root (irritation, impingement, or compression) causes leg pain than back pain.
- -L4: Patellar reflex, knee
- -L5 : Toe Thumb sensation, heel walk
- -S1 –Achilles reflex, toe walk, Pinky toe
- Red flags*: Rely on comprehensive clinical approach over red flags because patient can have red flags but not have a serious condition of back pain.
- Red flags* = TUNA FISH
T = Trauma U = Unexpected weight loss N = Neurologic symptoms A = Age > 50
F = Fever I = IVDU S = Steroid Use H = History of Cancer (prostate, Renal, Breast, Lung)
Cauda Equina Syndrome
Disc herniation (@ L4-5) compresses sacral nerve roots (S2-S4)
Symptoms: low back pain, radiates down the leg, numbness around the anus, and loss of bowel or bladder control.
Impingement of S2-4 causes
- Bowel dysfunction (decreased rectal tone)
- Bladder dysfunction
- Sexual dysfunction
- Saddle anesthesia
Emergent surgery is imperative!!!!!!
Delay can result in irreversible paralysis.
Life threatening
Lumbosacral Strains and Sprains
Strain: muscles and tendons that support the spine are twisted, pulled or torn. From single improper lifting or overstressing, or chronic (repetitive overuse)
Sprain: ligament stretch or tear. From fall, sudden twist, or block to body
Patient points to muscle, not bone (like with compression fracture)
Symptoms: Pain worse with movement, muscle cramps or spasms, pop or tear at injury, difficulty walking, bending, standing straight
Diagnosis: Discrete tender points in the lumbar tissue/paraspinal muscle region. No neurological deficits
Psoas Syndrome (Flexion Contracture of the Iliopsoas)
Causes: injury/shortening/spasm of iliopsoas muscle, jumping and running athletes, backpackers, sitting and stand up abruptly
Symptoms: Lower back pain (MC symptom), pain in butt, groin, down leg, limping or shuffling stride
Diagnosis: Tender point at iliacus (medial to ASIS), +Thomas test, +FABER
Short Leg Syndrome
discrepancy in leg lengths resulting in chronic leg and back pain, tilts the pelvis down on one side placing abnormal stress on the muscles and spine.
Anatomical short leg: one leg is longer and can be corrected with a heel lift in the shoe of the short leg.
- OMT for heel raise: raises pelvis and straightens spinal curves (which orginally compensated for tilted pelvis)
Functional short leg: an apparent short leg although structurally both legs are the same length when measured.
Sacroiliitis (inflammation of either or both iliac & sacral joints)
Pain in butt, lower back, down leg(s), pain with standing, climbing stairs, weight on one leg, running, big stride (like athletes)
Positive FABER test with buttock pain, not groin pain.
Positive Straight Leg Raise at >70
Spinal Stenosis
Narrowing of spine, pressure on nerves
Lower back and neck
Over 50 y/o
Degenerative lumbar stenosis is common in elderly
Some patients experience Neurogenic claudication (low back pain, leg pain, numbness, and motor weakness that starts or intensifies on standing or walking and is eased by sitting or lying down)
– Vascular claudication if patient has SOB
More leg pain than back pain, improves with rest or flexed spine (opens canal)
Unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)
Osteoarthritis (Spondylosis)
Associated with osteophytes (causing jagged points), seleroris (bone grows together and solidifies), borrowed discs
Onset of symptoms (20-50 y/o)
Lumbar spondylosis MC with over 40 y/o
Causes: Aging, genetics, injuries
Symptoms: Pain, stiffness, occasional numbness
Spondylolysis
Small stress fracture of vertebrae
More in younger people (teen-age growth spurt), student athletes (constant hyperextending spine)
Typically diagnosed at 15-16 y/o, more males. May go undiagnosed.
Symptoms: MCC of LBP in less than 26 y/o, worses with spine extension
Dx: oblique view of lumbar spine. Fracture of par interarticularis or “Collar of Scotty Dog” usually at L5/S1
Spondylolisthesis
Anterior displacement of vertebral body, might press on nerve
All ages, may go undiagnosed
Degenerative spondylolisthesis for over 40 y/o. With aging, the discs lose water, becoming less spongy and less able to resist movement by the vertebrae.
Symptoms: MC is lower back pain, feels like muscle strain, tight hamstrings (short strides with knees bent), leg pain (better with rest or flexed spine, worse with standing)
Dx: step off sign, palpate lumbar spinous process, lateral view of x ray
Connective tissue diseases
General Presentation?
Two subtypes?
General Presentation: Multiple joint arthralgia, fever, weight loss, fatigue, other joint tenderness
Rheumatoid Arthritis (RA): MC connective tissue (autoimmune) diseases, inherited. Systemic disorder, immune cells attack and inflame the membrane around joints. Back and hand pain.
Systemic Lupus Erythematosus (aka. Lupus or SLE ): systemic autoimmune disease Inflammation caused by lupus can affect joints, skin, kidneys, blood cells, brain, heart and lungs.
Spondyloarthropathies
forms of arthritis that usually affects the bones in your spine and nearby joints.
Arthralgia means pain in a joint.
Oligoarticular means affecting a few joints (< 4 or 5)
Polyarthralgia means pain in several joints (two or more)
Dx: physical signs of articular inflammation or the physical or X-ray signs of osteoarthritis.
Arthritis causes inflammation (swelling, redness and pain) in your body’s joints.
Intermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis (arched back) to lumbar flexion (bend forward).
Spondyloarthropathies: Ankylosing spondylitis (MC form)
Prevalence of HLA-B27
White males, 15-40 y/o
Inflammatory back pain, gradual onset and a dull quality, radiates into the gluteal regions. Worse in the morning, improves with activity, and has a nocturnal component. Associated with sacroiliitis. Symmetric joint distribution.
Bamboo spine
Spondyloarthropathies: Reactive Arthritis
After an UTI or infection of the digestive system.
Tends to attack asymmetrical LE joints.
Swelling in joints
Looks like STI or eye infection
Males in late teens to early adulthood, nail changes (onycholysis), skin lesions (not plaques), Reiter’s syndrome (Eye, Urethra and Joint inflammation-(Uveitis, urethritis/cervicitis, arthritis))
Spondyloarthropathies: Psoriatic Arthritis
Affects major joints of the body, as well as the fingers and toes, along with the back and pelvis. Typically asymmetric.
Causes: Psoriasis or FmHx of it
M/F (1:1) age 35-45
Symptoms: nail changes (pitting, onycholysis), skin lesions, can also have uveitis
Malignancy (Cancer metastasizes to bone)
Signs/Symptoms: Pain worsens in prone position, recent weight loss, fatigue
Exam: Typically have spinous process tenderness with metastasis to the spine.
Life threatening
Vertebral diskitis/Osteomyelitis
Inflammation between discs, swelling, pain with pressure
Osteomyelitis: from infection
Causes: Diabetes, any immune deficiency, and vascular disease, IV Drug abuse, and alcoholism
Symptoms: Severe back pain with or without fever and local tenderness in the spinal column. Nerve root pain radiating from the infected area. Weakness of voluntary muscles and bowel/bladder dysfunction.
Dx: Constant pain, spinous process tenderness, often no fever.
Scurvy
Vitamin C deficiency
Osteogenesis Imperfecta
Blue sclera, multiple fractures
Ehler-Danlos Syndrome
Collagen dysfunction, joint hypermobility, stretchy skin, multiple join pains, droopy eyelids, myopia, antimongoloid slant
Alport Syndrome
deafness, kidney dysfunction
Menkes Disease
Copper deficiency- kinky hair, growth failure, deterioration of nervous system
Shoulder Pain
3rd most common musculoskeletal complaint
Prevelance 16% to 34% of the general population
- *The only joint in the human body where tendons (rotator cuff) pass between bones (acromion and humerus)**
- -great flexibility
- -Great Susceptibility to injury
Traumatic causes: Fractures, dislocations, soft tissue injuries (ligamentous, tendon, or myofascial injuries), joint cartilage or capsule injury
Atraumatic causes:
Extrinsic:
- -> Referred no shoulder pathology at all
- -> Shoulder exam normal despite shoulder pain
Intrinsic:
- The shoulder as a whole
- ->Intra-articular
- ->Extra-articular
Fractures
Clavicle Fractures
most occur in kids and young adults
Proximal humerus fractures
most commonly in the elderly
Scapular fracture
Associated with blunt trauma
Glenohumeral Dislocation (Dislocated Shoulder)
50 percent of all major joint dislocations
3 types:
Anterior dislocation
most common
accounting for 95 to 97 percent of cases
Posterior dislocation
2 to 4 percent
Inferior dislocation (luxatio erecta, which means "to place upward") 0.5 percent
usually described as sudden, sharp pain
Acromioclavicular Joint Injuries
usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) with the arm adducted, such as a direct blow or falling onto the shoulder
Spectrum of injuries:
AC sprain, AC ligament rupture, and then sprain and rupture of the stronger coracoclavicular (CC) ligaments
Physical Exam:
tenderness directly over the AC joint, possibly associated with deformity, pain with ROM (especially abduction)
Diagnostic testing: a single anterior-posterior (AP) radiographs including both AC joints or US
Rotator Cuff Injuries
Supraspinatus is most often injured
Repetitive overhead activity in sport or work is a major risk factor
Symptoms: shoulder pain (over the lateral deltoid) more prevalent with overhead activity and at night, weakness
Impingement syndrome:
–>symptoms resulting from compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process
Tendon Injury:
- ->Sprain or Tear (partial or complete)
- ->occur as the end result of chronic subacromial impingement, progressive tendon degeneration, traumatic injury, or a combination of these factors.
- ->Most injuries occur primarily in the supraspinatus tendon
Tendinopathy
- -> chronic injury to the supraspinatus (abduction) and/or infraspinatus (external rotation) tendons.
- -> develops as a consequence of repetitive activity, generally at or above shoulder height, which leads to tendon degeneration and microvascular insult.
Specialty test: painful arc test (most sensitive and specific), Neer impingement sign, Hawkins impingement sign, Empty can test, Drop arm test
Extrinsic (Referred) Causes of Shoulder Pain
Neurologic: Cervical radiculopathy (C5-C6) Brachial plexus lesions Herpes Zoster Spinal cord lesion Cervical Spine DJD Thoracic Outlet Syndrome
Abdominal:
Hepatobiliary disease
Diaphragmatic irritation
Intraperitoneal blood, perforated viscus
Cardiovascular:
Acute Myocardial Infarction
Axillary vein thrombosis
Pulmonary:
Upper lobe Pneumonia
Apical lung tumor
Pulmonary Embolism
Intrinsic Causes of Shoulder Pain
Overuse injuries Shoulder instability Rotator cuff tendinopathy or impingement syndrome Subarcomial bursitis Synovitis Adhesive capsulitis Bicepital tendinitis Osteoarthritis Myofascial pain Septic arthritis Gout/pseudo gout
