Exam 3 Flashcards
monosodium urate crystals
hyperuricemia (purine metabolism = uric acid)
95% underexcreters (mostly decrease renal function)
stage I - asymptomatic, no treatment needed
stage II - acute, severe attack of 1 joint
stage III - after 10+ years of acute attacks, chronic swelling and tophi
rapid onset pain, redness, warmth
PODAGRA - MTP joint of great toe
often recurrent
Gout
Gout diagnostics and treatment
radiography = joint erosion arthrocentesis = (-) BIREFRINGENT
Treatment: analgesia, NSAIDs (indomethacin or Naproxen)
Colchicine (diarrhea side effect)
glucocorticoids if can’t take NSAID or colchicine - sugar can rise in DM pts
*Urate-Lowering Therapy - goal to maintain serum uric acid of 6.0 or less
Probenecid - uricosuric agent
–> underexcreters only and avoid in pt with ASA (aspirin) use or nephrolithiasis (kidney stones)
Allopurinol (Zyloprim) and Febuxostat (Uloric) - xanthine oxidase inhibitors
Agent of Choice - Allopurinol - good for both over and underexcreters
Prophylaxis with colchicine or NSAID first, then initiate urate-lowering therapy
–> may precipitate an acute attack
calcium pyrophosphate dihydrate (CPP) crystals
comorbidities
acute, typically mono-articular - 50% knees
may mimic RA, OA or septic arthritis
self-limited
Pseudogout (chondrocalcinosis or CPPD deposition disease)
Pseudogout diagnostics and treatment
synovial fluid aspiration - (+) BIREFRINGENT
Treatment: NSAIDs or cholchicine glucocorticoids (oral or systemic) if above doesn't work remove crystals via joint aspiration ice joint immobilization
considered chronic if 3+ attacks in a year
autoantibodies to nuclear antigens (inflammatory autoimmune disorder)
multi system disease
more common in blacks and females
fever, fatigue, weight change malar rash photosensitivity symmetric nonerosive arthritis Raynaud's phenomenon (white - blue - red episodic vasospastic disease) serositis (cardiopulmonary inflammation)
Systemic Lupus Erythematous (SLE)
Systemic Lupus Erythematous (SLE) diagnostics and treatment
ANA –> anti-dsDNA and anti-Sm subtypes
C3 and C4 - complement system
CBC, ESR (erythrocyte sedimentation rate/sed rate)
imaging if needed
Treatment: sun protection, diet, exercise, etc.
NSAIDs and rest for mild sxs
cytotoxic/immunosuppressive agents (ie. methotrexate) for severe sxs
systemic corticosteroids
antimalarials - hydroxychloroquine (Plaquenil) with ophthalmology f/u
drug-induced SLE (HIP drugs among others - hydralazine, isoniazid, procainamide)
–> (+) antihistone antibody
chronic, systemic autoimmune disorder
diminished exocrine gland function (salivary & lacrimal)
more common in females
common association with SLE, RA and systemic sclerosis
SICCA complex - dry eyes, dry mouth --> keratoconjunctivitis, xerostomia arthritis/arthralgia parotid gland enlargement fatigue Raynaud's
Sjogren Syndrome (SS)
Sjogren Syndrome (SS) diagnostics and treatment
ANA –> anti-Ro.SSA and anti-La/SSB subtypes
Schemer’s test - tear production
salivary gland biopsy
Treatment: regular f/u with dentist and ophthalmologist
dry eyes –> artificial tears, cyclosporine drops
xerostomia - biotene OTC (saliva substitute)
steroids
rare, chronic autoimmune disorder diffuse FIBROSIS of skin and internal organs skin appears taut and shiny 2 forms: limited (80%) diffuse (20%) more common in females
arthralgia/arthritis
pericarditis
renal and pulmonary HTN
limited: CREST syndrome calcinosis cutis (calcification of subQ tissues) Raynaud's esophageal dysmotility sclerodactyly (puffy hands) telangiectasia
diffuse (worse prognosis):
rapid development of symmetric skin thickening on trunk and proximal extremities
more likely to have significant internal organ damage
Systemic Sclerosis (Scleroderma)
Systemic Sclerosis (Scleroderma) diagnostics and treatment
ANA –> anti-SCL-70
proteinuria (renal involvement)
Treatment: symptomatic and supportive
Raynaud’s - Nifedipine (Ca2+ channel blocker)
Esophageal - H2 blockers, H+ pump inhibitors, small more frequent meals
inflammatory arthritis triggered by antecedent GI/GU infection
HLA-B27 + (85%)
“can’t see, can’t pee, can’t climb a tree”
more common in men (post-GU infection)
acute, asymmetric oligoarthritis - often lower extremities
1-4 weeks post-GI/GU infection
diarrhea (GI) or urethritis (GI - “can’t pee”)
conjunctivitis (“can’t see”)
keratoderma blennorrhagicum on palms and soles
Reactive Arthritis (“Reiter’s Syndrome”)
Reactive Arthritis (“Reiter’s Syndrome”) treatment
NSAIDs - indomethacin
intra-articular/systemic glucocorticoids
methotrexate (MTX) or anti-TNF (cytotoxic/immunosuppressive) if above doesn’t work
sxs resolve 6-12 months
chronic, systemic, inflammatory autoimmune disorder
thickening of synovial membrane = inflammation (synovitis)
–> can lead to carpal tunnel over time
destruction of cartilage and bone
joint deformity and loss of fctn if not treated
gradual onset
symmetric polyarthritis
*morning stiffness for at least 1 hour
distal sites affected early - MCP and PIP joints
phys exam: ulnar deviation of MCP joints Boutonniere deformity (PIP) Swan neck deformity (DIP) - more severe disease tenderness/swelling *rheumatoid nodules = unfavorable sign (elbows)
Rheumatoid Arthritis (RA)
Rheumatoid Arthritis (RA) diagnostics and treatment
radiography - preferred initial --> soft tissue swelling around joint --> periarticular osteopenia (thinning bones around joint) --> narrowing joint space --> subluxation/dislocation --> bone erosion and joint obliteration MRI and U/S to check for synovitis joint aspiration if unsure
Lab: CBC/ESR
rheumatoid factor (RF) –> (+) early in course = more severe
anti-CCP antibodies (newer and more specific)
ANA (non-specific)
Treatment: control synovitis, prevent joint injury, preserve ADLs
NSAIDs + glucocorticoids
DMARDs (disease modifying anti-rheumatic drugs)
–> slows/halts disease progression
–> refer to Rheumatology
ex. methotrexate, sulfasalazine (synthetic)
ex. TNF inhibitors Enbrel, Remicaid, Humira (biologic) - risky
*CVD most common cause of death
degenerative joint/disk disease
risks: age, female, obesity, genetic, general wear/tear
pain exacerbated by activity and relieved by rest
morning stiffness typically resolves in less than 30 min
typically hands, knee, hip, pine
crepitus bony enlargement decreased ROM and malalignment tenderness Bouchard's nodes (PIP) Heberden's nodes (DIP) 1st carpometacarpal joint (CMC) osteophytes effusions pain around hip/groin referred to knee cervical and lumbar spondylosis
Osteoarthritis (OA)
Osteoarthritis (OA) diagnostics and treatment
radiological: joint space narrowing
osteophytes
subchondral sclerosis and cysts
(-) RF and anti-CCP
no joint obliteration like RA
Treatment: pain control
minimize disability and pt education
NSAIDs (ie. diclofenac)
narcotics - sparingly if at all
intra-articular glucocorticoids
–> no more than 2-3 times per year - atrophy to cartilage
surgical = joint replacement or resurfacing
chronic inflammatory rheumatic condition
*association with giant cell (temporal) arteritis
gradual onset symmetric stiffness at least 30min
shoulder pain > hip and neck (proximal regions)
synovitis and bursitis
edema
decreased ROM
“gel” phenomenon = stiffness after periods of rest
Polymyalgia Rheumatica (PMR)
Polymyalgia Rheumatica (PMR) diagnostics and treatment
elevated ESR (>40)
(-) ANA, RF, anti-CCP
imaging - x-ray, MRI, U/S
*general rule of thumb:
male = age/2 = ESR
female = (age + 10)/2 = ESR
Treatment: RAPID RESOLUTION with low dose glucocorticoids (ie. prednisone)
MTX or TNF inhibitors for select pts
PT
NSAIDs
soft tissue pain disorder - muscles, tendons, ligaments
widespread, chronic
women 20-55yo = common complaint
no tissue inflammation
aching stiffness fatigue paresthesia hard time explaining what hurts headaches insomnia superficial pain in 11/18 tender points
Fibromyalgia
Fibromyalgia treatment
cyclobenzaprine - muscle relaxer
antidepressant - amitriptyline, cymbalta (SNRIs)
anticonvulsants - Lyrica, Neurontin (gabapentin)
psych referral
*avoid narcotics - addiction
non-displaced
fragments in anatomic alignment
displaced
fragments no longer in usual alignment
angulated
fragments maligned and angular
bayonetted
distal fragment longitudinally overlaps proximal fragment
distracted
distal fragment separated from proximal fragment by a gap
closed
skin over and near fracture intact
open
skin over and near fracture lacerated or abraded by the injury –> REFER
transverse
perpendicular to shaft of bone
comminuted
2+ fragments of fracture
oblique
angulated fracture line
segmental
type of comminuted fx in which a completely separate segment of bone is bordered by fx lines
spiral
multiplanar and complex fx line (common in ski injuries)
intra-articular
fx line crosses articular cartilage and enters the joint
torus
incomplete buckle fx of one cortex often seen in children
greenstick
incomplete fx with angular deformity seen in children
almost like it bends and one side breaks but the other doesn’t
impaction
one bone hits or “impacts” an adjacent bone
compression
type of impaction fx that occurs in vertebrae resulting in depression of end plates
often in older people with osteoporosis
depression
type of impaction fx that occurs in the knee when the femoral condyle strikes softer tibial plateau
stress (fatigue)
fx in normal bone that has been subjected to repeated or cyclical loads that in and of themselves are not sufficient to cause a fx
stress (insufficiency)
fx in weakened bone that has been subjected to a load insufficient to fx a normal bone
pathologic
fx through bone weaker by tumor, metabolic bone disease or osteoporosis
SITS muscles (SIT = ext rot & ABd, S = int rot)
pain over anterior and lateral aspects of shoulder that radiates to deltoid and progressively worsens
decreased ROM (inability to ABduct above shoulder)
shoulder may catch/click
subacromial tenderness
Drop arm and empty can tests
acute tear = often labral pathology
chronic tear = pain usually worse at night, gradual weakness does NOT improve with analgesics
Rotator Cuff Tear
Rotator Cuff Tear diagnostics and treatment
lidocaine injection test
radiograph - elevation of humeral head 1+cm
*MR ARTHROGRAM (good for labral pathology too)
Treatment: ice and NSAIDs
weighted pendulum stretching with some shoulder immobilization
PT
if persistent, subacromial steroid injection or surgery
*principle cause of rotator cuff tendonitis
subacromial (pinpoint) tenderness
gradual pain in lateral shoulder that radiates to deltoid
normal glenohumeral joint ROM
*preserved strength
Neer’s and Hawkin’s tests (flexion, int rot maneuvers)
Shoulder Impingement Syndrome
Shoulder Impingement Syndrome diagnostics and treatment
radiography - normal in 1st episode pts
MRI useful for chronic sxs
Treatment: ice, NSAIDs, activity modification
*NO arm sling recommended
PT referral with f/u
if persistent, corticosteroid injections or surgery
stiffened glenohumeral joint
secondary to injury, trauma, overuse, sling use, bursitis
may develop adhesions
chronic pain with limited ROM due to mechanical restriction
Apley Scratch test –> comparison is key
ABduction and ext rot
Adhesive Capsulitis (“frozen shoulder”)
Adhesive Capsulitis (“frozen shoulder”) treatment
imaging isn’t helpful
Treatment: PT consult - stretch lining of joint
treat underlying process
complains of bump on shoulder that is worse at bedtime
AC joint swelling, tenderness and possible deformity
pain aggravated by downward traction
Cross-Over test –> pain with passive cross-body ADduction
sprain, partial or complete tear
Acromioclavicular (AC) Injury
Acromioclavicular (AC) Injury grading
Grade I - AC joint intact, point tender SPRAIN without separation, normal radiographs
Grade II - separation of superior and inferior AC ligaments, decreased ROM, instability with stress testing of AC joint, radiographic evidence (PARTIAL TEAR)
Grade III - separation of superior and inferior AC ligaments AND coracoclavicular ligament, severe pain, decreased ROM and instability
radiograph shows inferior margin of distal clavicle at or above superior margin of acromion (COMPLETE TEAR)
Acromioclavicular (AC) Injury treatment
shoulder immobilizer 3-4 weeks for comfort
ice, rest, NSAIDs
corticosteroid injection if not improving
surgical for Grade III (recent studies do not support)
tenderness to palpation over clavicle visual deformity seen decrease ROM apprehension and guarding single AP radiograph of clavicle
70-80% middle 1/3 - typically displaces superiorly
Clavicle Fracture
Clavicle Fracture treatment
sling/swathe or figure 8 harness
analgesics and muscle relaxers
sleep upright
ortho referral for all displace and proximal or distal fxs
–> surgery
inflammation or degeneration of sack-like structure
repetitive movement injury
pain to shoulder with ROM and rest
localized tenderness to palpation
warm, red, fever, malaise
*not often isolated and may cause impingement
Subacromial Bursitis
Subacromial Bursitis treatment
fluid aspiration if suspected sepsis, otherwise imaging provides little benefit
ice and NSAIDs
restriction of overuse
aspiration and corticosteroid injection
pain to anterior shoulder with ABduction and ext rot
popping sensation
weakness
Yergason’s and Speed’s tests
inflammation of long head of biceps tendon as it passes through bicipital groove
Biceps Tendonitis
Biceps Tendonitis treatment
U/S beneficial
NSAIDs and rest
PT
surgery
arm held in position of protection
–> SULCUS SIGN
apprehension and relocation tests
95% anterior –> SPECIAL CONSIDERATIONS
1. Bankart lesion
detachment of anterior inferior labrum from glenoid rim
2. Hill Sachs lesion
cortical depression of posterolateral humeral head when humeral head is impacted by anterior rim of glenoid
3. axillary n.
decreased sensation of lateral aspect of shoulder and decreased deltoid function
Glenohumeral Subluxation/Dislocation
Glenohumeral Subluxation/Dislocation treatment
PT
ice, rest, NSAIDs
shoulder immobilizer –> sling and swathe 2-4wks
surgery for repeat dislocations
localized pain and swelling
reproducible pain with wrist flexion (medial) or wrist extension (lateral) against resistance
overuse syndrome
Medial = Golfer’s elbow –> wrist flexor, pronator
Lateral = Tennis elbow –> wrist extensor, supinator
Elbow Epicondylitis
Elbow Epicondylitis treatment
acute = sling, wrist brace, ice and NSAIDs recurrent = steroid injections and surgery for debridement preventative = forearm strap and decreased repetitive activities
swelling of the elbow
+/- pain
+/- ROM
infection = erythema and warmth
cause: trauma, infection, rheumatologic condition
Olecranon Bursitis
Olecranon Bursitis treatment
ice and NSAIDs
aspiration
antibiotics +/- surgical intervention if infected
decreased grip strength
RF and SF tingling and numbness
chronic = muscle wasting
ulnar n. compression
Cubital Tunnel
Cubital Tunnel treatment
radiographs and nerve conduction studies
NSAIDs
bracing
PT
surgery
gradual, progressive pain --> early = intermittent, late = burning, numbness, tingling sxs worse at night *thenar muscle atrophy decreased grip strength decreased sensory to thumb, IF, LF
Tinel’s and Phalen’s tests
swelling of synovium or thickening of transverse carpal ligament causing compression of median n.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome diagnostics and treatment
nerve conduction study = delayed because demyelination
EMG = denervated muscle spontaneously fires
Treatment: acute = immediate decompression
chronic = NSAIDs, corticosteroid injection, brace, PT, surgery
soft mobile mass
commonly on dorsal radial and solar aspects of wrist
fluctuates in size often with activity
may decrease ROM and become painful
collection of synovial fluid within a joint or tendon sheath
Ganglion Cyst
Ganglion Cyst treatment
NSAIDs
aspiration and steroid injection
surgery for recurrence (50% come back)
may resolve spontaneously
pain and swelling along dorsal radial wrist
pain aggravated by thumb and wrist motion
Finkelstein test
inflammation of 1st dorsal compartment due to overuse
De Quervain’s Tenosynovitis
De Quervain’s Tenosynovitis treatment
decreased repetitive activity thumb spica immobilization NSAIDs steroid injections surgery for decompression
painless nodules that turn into palpable cords
extension loss of fingers (usually RF & SF)
Hueston Table Top test - ability to flatten hand on table
progressive fibrosis of palmar fascia
connective tissue disorder
Dupuytren’s Contracture
Dupuytren’s Contracture treatment
observation
refer for surgery if progressive
glucocorticoid injection for pain or rapid growth of nodules
nodule forms at solar aspect of MCP causing mechanical impingement and inflammation
digit snaps/catches/locks with passive and active ROM at IP/PIP joints
progressively painful
nodule unable to slide through A1 pulley
Trigger Thumb/Finger (Stenosing Flexor Tenosynovitis)
Trigger Thumb/Finger (Stenosing Flexor Tenosynovitis) treatment
NSAIDs
local corticosteroid injection
surgery to release A1 pulley
gradual neck stiffness and soreness muscle tightness HA (tension) starting at base of skill shoulder pain decreased ROM due to pain neuro exam normal tenderness to palpation
usually 2-24 hrs post-injury (adrenaline)
Cervical Strain/Sprain
Cervical Strain/Sprain treatment
radiograph - AP/ lateral/odontoid with flexion/extension views
MRI only if neuro deficit
“therapeutic trial” for 48 hours - rest, ice/heat, massage
NSAIDs, muscle relaxants - 48-72hrs around the clock, not PRN
narcotics for limited course if necessary
PT - TENS unit application
anti-depressants if chronic
majority recover in 4 wks
ACUTE onset pain secondary to identifiable precipitating event
pain worsens with activity and radiates to butt
decreased ROM due to pain
neuro exam normal
tenderness to palpation
30-60% have had prior episodes
Lumbar Strain/Sprain
Lumbar Strain/Sprain treatment
radiograph - AP/ lateral/odontoid with flexion/extension views
MRI only if neuro deficit
“therapeutic trial” for 48 hours - rest, ice/heat, massage
NSAIDs, muscle relaxants - 48-72hrs around the clock, not PRN
narcotics for limited course if necessary
PT - TENS unit application
anti-depressants if chronic
majority recover in 4 wks
variable clinical presentation
1 level with unilateral, radicular sxs
multiple levels with bilateral sxs
may see signs consistent with myelopathy if central disc herniation causes cord compression
neck tenderness or muscle spasm
correlate plain films with MRI
–> narrowing disc space and bone spurs (osteophytes)
combo degenerative disc disease and hypertrophy of ligamentum flavum and facets
Cervical Spondylosis
Myelopathy
upper motor neuron (UMN) hyperactive reflexes --> clonus spasticity upgoing toes (Babinski's sign) late muscle atrophy weakness in affected distribution
Radiculopathy
lower motor neuron (LMN) hypoactive reflexes flaccidity fasciculations muscle atrophy weakness in affected distribution
acute to severe pain
radiates from low back to legs (“sciatica”) in 95% of cases
pain aggravated by sitting, coughing, sneezing
may see trunk shift to one side
Straight Leg Raise test (SLR)
Achilles Tendon reflex if L5-S1 herniation (S1 nerve root)
most common at L4-5 and L5-S1
most posterolateral because posterior longitudinal ligament (PLL) is weakest
Herniated Lumbar Disk Disease
Herniated Lumbar Disk Disease diagnostics and treatment
radiographs - decreased height of disc space and osteophytes
MRI = diagnostic
NSAIDs/analgesics (ibuprofen or naproxen)
muscle relaxants (cyclobenzaprine/flexeril)
NO narcotics
heat/cold
PT
urgent referral if neuro deficits –> surgery
urinary retention in 90%
bilateral lower extremity muscle weakness
acute LBP with sciatica due to massive midline herniation
“SADDLE” anesthesia - numb wherever you sit
decreased anal sphincter tone –> rectal exam
*neurologic emergency = REFER
Cauda Equina Syndrome
Cauda Equina Syndrome treatment
MRI is diagnostic
disc herniation or trauma = urgent surgical decompression
metastatic disease = urgent oncology consult for radiation
back pain aggravated by bending, lifting, twisting
may have “step off” of spinal processes on exam
associated with degenerative disc disease
anterior displacement of one vertebrae on another
*graded by % –> less than 50% = asymptomatic
Spondylolithesis
Spondylolithesis treatment
50% = spinal fusion to stabilize
any neuro impairment = REFER
neurogenic claudication = progressive LBP and bilateral leg pain aggravated by standing and/or walking
relieved by leaning forward
congenital or acquired condition that narrows neural foramen causing compression
Lumbar Spinal Stenosis
Lumbar Spinal Stenosis diagnostics and treatment
decreased height of intervertebral discs
facet hypertrophy
hypertrophy of ligamentum flavum
narrowing of intervertebral foramina
NSAIDs
PT
epidural steroid injections for pain
Spinal Tumors
new onset LBP in patient with known malignancy is metastasis until proven otherwise
back pain malaise fever sepsis wound drainage
osteomyelitis (infection of bone) - rare and commonly associated with invasive procedures
Spinal Infections
Spinal Infections treatment
antibiotics
surgical drainage
aching LBP around SI joint that progresses proximally
persistent morning back stiffness 1+hr
–> exacerbated by inactivity and improves with activity
low grade fever, fatigue, weight loss, night sweats
*acute anterior uveitis/iritis (circumcorneal flush)
*limited spinal motion
tenderness over joint
loss of lumbar lordosis
accentuation of thoracic kyphosis
Shober test –> mark 10cm above an 5cm below intersection of iliac crest and spine
ask pt to forward flex as much as possible
re-measure distance –> should be 20+cm (5cm change)
Ankylosing Spondylitis
Ankylosing Spondylitis diagnostics and treatment
radiograph = BAMBOO SPINE - fusion of vertebral bodies
1st line - NSAIDs - indomethacin, celecoxib (Celebrex)
2nd line - refer to Rheumatology - TNF antagonists (i.e. sulfasalazine)
intra-articular steroids no more than every 3-4mo
anti-depressants
refer to ophthalmology if uveitis
surgery
PT - supportive measures
groin or lateral hip pain
sharp stabbing or dull ache
aggravated by turning, twisting, prolonged standing and squatting
*FADIR test (flexion, ADduction, internal rotation of hip) FABER test (flexion, ABduction, external rotation of hip)
bone overgrowth or abnormality in bone development can change the function of the hip joint
2 types: pincer = acetabular involvement
Cam = femoral head involvement
could be combo of pincer and Cam lesions
Femoroacetabular Impingement (FAI)
Femoroacetabular Impingement (FAI) diagnostics and treatment
x-rays initially
CT/MRI if needed
NSAIDs
PT
decrease aggravating activities
surgical eval if conservative tx fails
dull or sharp groin pain catching/clicking radiates to lateral hip, anterior thigh or butt insidious onset vs. acute trauma FADIR/FABER tests ROM and strength testing
Labral Tear of the Hip
Labral Tear of the Hip diagnostics and treatment
*MR Arthrogram (test of choice for labral tears)
x-rays
MRI
conservative vs. referral for surgical consultation
painful or painless snapping/popping aggravated by activity
pseudosubluxation
external = passive internal/external rotation of hip while laying on side (IT band over g greater trochanter)
internal = FABER test then extend hip to check snapping (iliopsoas tendon over iliopectineal eminence or femoral head)
increased risk in adolescents and dancers
Snapping Hip Syndrome
Snapping Hip Syndrome treatment
NSAIDs
+/- corticosteroid injection
PT - stretching and heat/ice
surgery rarely indicated
lateral hip pain localized to greater trochanter pain with resisted abduction Trendelenburg sign (hip drop on contralateral side)
repetitive overload tendinopathy (gluteus medius and minimus)
Greater Trochanteric Pain Syndrome (Trochanteric Bursitis)
Greater Trochanteric Pain Syndrome (Trochanteric Bursitis) treatment
self-limiting NSAIDs ice (acute) or heat (chronic) adjust positioning steroid injection into bursa
most common MOI: knee flexion with foot planted
lateral impact with valgus stress and rotation
Valgus stress test = MCL
Varus stress test = LCL
Unhappy Triad (Triad of O’Donoghue)
ACL
MCL
Medial Meniscus
Medial Collateral Ligament (MCL) Sprain
joint effusion (hemarthosis)
guarding
laxity
pt hears/feels a “pop” followed by immediate pain, swelling and instability
*Lachman’s test - stabilize distal femur and pull on tibia anteriorly
Anterior Drawer test
Pivot Shift test
more common in females (increased Q angle = increased values stress)
*prevents anterior translation of the tibia
>50% associated with meniscus injury
Anterior Cruciate Ligament (ACL) Injury
Anterior Cruciate Ligament (ACL) Injury treatment
RICE (rest, ice, compression, elevation) refer to ortho surgery for young patients and athletes brace PT - rehab
mild to moderate knee effusion and hemarthrosis
generalized knee pain
limp
often missed because subtle or associate with high energy trauma
Posterior Drawer test
Posterior Sag sign
prevents posterior translation of tibia
largest and strongest ligament of the knee
Posterior Cruciate Ligament (PCL) Injury
joint line pain
inability to fully extend knee - locking/catching
walking up and down stairs and squatting is painful
McMurray’s test - external rotation of heel, flex maximally, then slowly provide values stress while extending
Apley’s compression/distraction test
C-shaped cartilage that increases contact area for articulation –> aids in joint stability and shock absorption
can often result in arthritis later because bone on bone
Meniscus Injury
Meniscus Injury treatment
consider location and extent of teat
conservative vs. surgical
MRI may help
Knee “Sprains” Grading and Treatment
Grade I - mild stretch
RICE, WB as tol
Grade II - partial tear
RICE, brace immobilization, +/- crutches, PT, possible surgery
Grade III - complete tear
REFER –> surgical repair, crutches, brace, aggressive PT
anterior pain under patella
pain worsens when going up and down stairs
+ theater/long car ride sign
crepitus, popping and instability
Patellar glide test
apprehension test
*most common knee complaint in primary care
malalignment, patellar tracking concerns
Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome treatment
ice and NSAIDs
PT
brace PRN
no imaging needed
often asymptomatic
pain/swelling may occur behind knee
accumulation of joint fluid in popliteal fossa
Baker’s Cyst (Popliteal Cyst)
Baker’s Cyst (Popliteal Cyst) treatment
NSAID
aspiration/injection
compression brace
pinpoint tenderness inferior to patella
inflammation from repetitive trauma
Patellar Tendonitis (“Jumper’s Knee”)
Patellar Tendonitis (“Jumper’s Knee”) treatment
ice, NSAIDs, bracing/strapping
rest
PT
gradual onset localized pain
initial sharp/burning during activity
develops into constant deep ache
overuse injury
evaluate for limb length discrepancy
Iliotibial Band Syndrome (ITBS)
Iliotibial Band Syndrome (ITBS) treatment
RICE
NSAIDs
PT
pain, swelling, tenderness to the knee
r/o infection
pre-patellar and pes anserine are most common site of inflammation
Knee Bursitis
Knee Bursitis treatment
NSAIDs
aspiration/steroid injections
padding/bracing
chronic pain usually in knee, ankle or elbow
catching.clicking if something is caught there
lesion of cartilage and underlying bone that results in necrosis and possible displacement
Osteochondritis Dissecans (OCD)
Osteochondritis Dissecans (OCD) treatment
*MRI will pick it up
long term bracing
activity restrictions
PT
surgery
swelling/pain at the ankle
ecchymosis
difficulty WB
eval for bone pain
lateral ligament complex (most commonly injured) INVERSION with plantar flexion Anterior Drawer test medial = deltoid ligament complex EVERSION syndesmotic = high ankle sprain Squeeze test
Ankle Sprains
Ankle Sprains treatment
radiograph only to r/o fx
RICE
NSAIDs
+/- short immobilization for grade 2-3
PT
recent increase in training resulting in burning pain
or
sudden pivoting or rapid acceleration
palpate along tendon for pain, edema or defect
have pt do active ROM first - plantar and dorsiflexion
Thompson test
peds = Sever’s disease (inflammation at growth plate)
Achilles Tendon
Achilles Tendon treatment
ortho referral - conservative vs. surgery
immobilization - boot allowing for continuous plantar flex position
pain with onset of walking (first step in the morning)
unilateral or bilateral
point tenderness aggravated by ROM
r/o S1 radiculopathy (SLR and achilles tendon reflex tests)
inflammation of fascia from activity, poor shoe wear, ankle pronation, heel spurs, etc.
Plantar Fasciitis
Plantar Fasciitis treatment
ice, rest, NSAIDs
PT
improve shoe wear
if severe = steroid injection, splinting, casting
progressive bone loss with increased risk of fx
prevent with Ca2+/Vitamin D and exercise
evaluate with DEXA scan for bone densitometry
Osteoporosis
Osteoporosis treatment
estrogen replacement therapy - Raloxifine (Evista)
calcitonin
bisphosphates - alendronate (fosamax), risedronate (actonel), ibandronate (boniva)
increased pain in the joints redness warmth inflammation *Surgical emergency
Septic Arthritis
Septic Arthritis diagnostics and treatment
joint aspiration - gram stain, fungi, crystals, etc.
CBC, ESR, CRP, cultures
IV antibiotics
most common benign tumor
fluid-filled cavity in bone
cortex still intact
radiographs, MRI/CT if needed, bone scan
Treatment: may resolve spontaneously
consider surgery for recurrent pathologic fxs
Unicameral Bone Cyst (UBC)
blood filled cyst in bone
spine and extremities most often affected
benign but aggressive
radiography, MRI, biopsy
Treatment: refer to ortho for surgery
Aneurysmal Bone Cyst (ABC)
benign lesion
metaphyseal, eccentric (edge of bone), sclerotic borders
looks like bubbles
asymptomatic and typically incidental finding
Treatment: observe with serial radiographs
ortho referral is lesion is >50% diameter of bone
Non-ossifying Fibroma (NOF)
benign aggressive tumor
may develop as growth plate closes
localized pain and weakness
radiographs, MRI, bone scan (hot spot)
Treatment: refer to ortho for radiation and surgery
Giant Cell Tumor (GCT)
small benign tumor
*nidus-center of growing cells surrounded by thickening bone
severe pinpoint pain at night resolved immediately from taking NSAIDs
Treatment: refer to ortho or interventional radiology for radio frequency ablation
Osteoid Osteoma
fixed, non-mobile mass near joints
pain with activity
tingling/numbness if near nerve
benign, abnormal growth of bone and cartilage along surface of bone
Treatment: observation and refer if painful
Osteochondroma (Exostosis)
asymptomatic vs. pain/swelling
pathologic fx
malignant primary bone tumor - rapidly growing
*most common bone tumor in children
radiographs, MRI/CT
Treatment: refer to ortho and oncology
Osteosarcoma and Ewing’s Sarcoma
pain and weakness
pelvic masses radiate pain to hip and bone
bone tumor of CARTILAGE-PRODUCING cells
Treatment: refer to ortho
+/- radiation and chemo
Chondrosarcoma
fatigue, fever, sweats
diffuse bone tenderness
pathologic fxs
most common primary bone tumor –> malignant bone marrow
involves entire skeleton
*Bence-Jones proteins in UA
punched-out appearance on imaging
Treatment: chemo, radiation, supportive
Multiple Myeloma
asymptomatic
anemia (labs)
bone scans
Lead Kettle (PB-KTL) prostate, breast, kidney, thyroid, lungs men = P and L woman = B
*REFER
Metastatic Bone Cancer
