FINAL msk Flashcards
What does a tendon do?
Connects muscle to bone
What are common sites of tendonitis?
Supraspinatus tendinitis of shoulder (rotator cuff)
Lateral and medial epicondylitis (tennis and golfer’s elbow)
Bicipital tendinitis
Gluteus medius/minimus tendinopathy
Achilles tendinopathy
Flexor carpi radialis and flexor carpi ulnaris tendinopathy
What are common causes of tendonitis/tendinopathies?
Overuse or sports injury
Inflammatory rheumatic disease
Metabolic disturbances such as calcium apatite deposition
Less common: use of fluoroquinolone antibiotics and statins
What are common symptoms of tendonitis/tendinopathies?
Local pain and dysfunction, inflammation and degeneration
Matching:
- Lateral Epicondylitis
- Medial Epicondylitis
A. Tennis elbow
B. Golfer’s elbow
Lateral = Tennis elbow
Medial = golfer’s elbow
What are risk factors for lateral and medial epicondylitis?
Activities involving repeated movements of the forearm, wrist, and fingers
Improper techniques doing certain movements
Improper equipment for work, daily activities, sports
Age – most common in 40s
History of tendon injury
Addition risks for Medial: sports that require repetitive valgus and flexion at the elbow (ex. golfers, tennis players, swimmers, pitchers, and javelin throwers), repetitive occupational tasks such as lifting and passing heavy objects
Lateral Epicondylitis is due to damage to the tendons of the extensor carpi radialis brevis (ECRB) and forearm extensor muscles, while medial epicondylitis relates to the tendons of pronator teres & flexor carpi radialis muscles. Explain the patho of what happens to these tendons
Caused by irritation and overstretching (using a repeated twisting motion) resulting in tissue degradation, loss of grip strength and pain
Forces cause microscopic tears in tissue
Initial inflammatory changes cause thickening of the tendon sheath, limiting movement and causing pain
Recurring microtears lead to remodeling/fibrosis
What is the time course of Epicondylitis?
Often begins gradually
Initially pain may only last 24 hours post-activity. As condition progresses, pain stays longer, becomes persistent without movement
Mild pain may improve in 6-8 weeks
Prolonged cases may improve in 6-12 months, in some cases pain lasts more than 2 years
What are signs and symptoms of Lateral Epicondylitis
Pain usually in dominant arm
Affects outside of elbow
Pain with both passive and resisted wrist extension with elbow extended
Pain increases when lateral area is pressed or when grasping or twisting objects
Elbow stiffness in the morning
Pain in other parts of body (shoulder, neck) as these areas try to compensate
What are signs and symptoms of Medial Epicondylitis
Affects the inside of the elbow
Pain with both passive and resisted wrist flexion with elbow in full extension
Pain occurs on the ulnar side of the forearm, the wrist and occasionally the fingers
Stiffness of the elbow, weakness in the hand and the wrist and a numb or tingling feeling in the fingers (mostly ring and little finger)
Local tenderness over medial epicondyle and the conjoined tendon of the flexor group
What could be informs the diagnosis of Epicondylitis?
Patient’s History (job, activities, onset of pain, location etc)
Physical Exam: location of tenderness)
X-ray to rule out other injuries
Golfers Elbow Test (passive and active)
What would be helpful for patient teaching in Epicondylitis?
resting the elbow
applying ice or heat several times a day for 1-2 weeks
Stopping or changing activities that irritate tendon (also important for prevention)
What are some possible treatments for Epicondylitis?
NSAIDs (topical or oral) for pain control
Physio to strengthen and increase flexibility, change of movements
Counterforce brace
If condition gets worse consider: Corticosteroid injection, Surgery (not done often)
De Quervain Tenosynovitis/Tendinopathy is another tendinopathy explored in this course, which muscles are involved in this case?
Affects the abductor pollcis longus (APL) and the extensor pollcis brevis (EPB) tendons.
Two of the main tendons to the thumb that assist with bringing the thumb out away from the index finger (APL) and straightening the joints of the thumb (EPB).
These two tendons arise from muscles in the forearm and then run together in a sheath that keeps them close to the bone as they cross over from the thumb side of the wrist into the hand.
Any swelling of the tendons (De Quervain’s ) and/or thickening of the sheath can result in a situation where the tendons no longer fit well inside the sheath.
What are the signs and symptoms of De Quervain tendinopathy?
pain and tenderness along the thumb side of the wrist.
This is particularly noticeable when: Moving the thumb, forming a fist, grasping or gripping something, turning the wrist, Lifting something with arms in front of you and thumbs pointed toward the ceiling (e.g., lifting a child)
May hear a funny sound like a squeak, crackle, snap, or creak when moving the wrist or thumb.
bottom of the thumb or the side of the wrist might also be sore or swollen. This can make it hard to move thumb or wrist.
back of the thumb and index finger may feel numb.
Sometimes can cause a small bump on the thumb side of the wrist. Without treatment, the pain can spread up forearm or down into thumb
What is the test used to help diagnose De Quervain tendinopathy
Finkelstein test - make a fist with thumb inside. Then bend wrist outward toward your little finger. If pain on the thumb side of wrist, then most likely have de Quervain’s.
Outline non-pharm treatment of De Quervain tendinopathy
Goal of treatment is to relieve the pain and swelling in thumb and wrist, and restore normal function:
Avoid moving the hand and wrist.
Until symptoms are better, stop the activities that caused the pain.
Keep wrist in a straight line with your arm by using a splint to keep thumb and wrist from moving.
Ice or heat
Gentle stretching exercises once symptoms are gone.
May need to see a physiotherapist or occupational therapist to help learn how to use wrist differently.
Outline pharm treatment of De Quervain tendinopathy
NSAIDs either topically or orally.
Acetaminophen
Possible corticosteroid shot, injected into wrist area and the bottom of thumb.
Within 3 weeks of having a steroid shot, most people can use the wrist and thumb again for normal activities. Most people feel better after just one shot, but might need another shot after 4 to 6 weeks. No more than 3 shots are used.
How often is surgical intervention needed for De Quervain tendinopathy?
Not very often, up to 80% of patients respond to non-surgical treatment
Which population are proximal humeral fractures most likely in?
Surgical neck fractures of the humerus are common in older people with FOOSH injuries
Humeral mid shaft fractures are caused by direct trauma and can damage which nerve?
Radial
Describe the most common types of proximal radius fracture
Radial head- more common in adults
Radial neck- more common in children
Can result from FOOSH or direct blow to elbow
Describe the signs and symptoms of a radial head fracture
Recall- proximal radius fracture caused by FOOSH (pushes radius into humerus) or direct trauma to elbow
S&S: pain, swelling, tenderness over lateral elbow; decreased elbow ROM; joint tenderness of radial head
Your patient suffers a direct blow to their forearm, causing fracture of the ulna. What is a common injury that co- occurs with this
Fracture of ulna often occurs with dislocation of the proximal radioulnar joint. This is called a Monteggia fracture
What nerve can a Monteggia fracture injure?
Monteggia fracture= fracture of ulnar + dislocation of proximal radio ulnar joint
Puts the radial nerve at risk
What is the most common type of forearm fracture?
Colles’ fracture accounts for 80% of forearm fractures.
What is a Colles fracture
Fracture of distal radius
Most often caused by FOOSH
Extension/ compression fracture of distal radius
Causes dorsal, proximal displacement of the distal fragment (dinner fork appearance- from side view, wrist is lower than hand) and radial deviation of hand
Describe the dinner fork appearance of a Colles fracture
Distal fragment is proximally and dorsally displaced
What is a Smith fracture?
Fracture of distal radius
Most often caused by fall on flexed hand
Results in ventral, proximal displacement of distal fragment (from side view, wrist is higher than hand)
What are signs and symptoms of a distal radius fracture?
Colles- dinner fork (dorsal proximal displacement of distal fragment)
Smoth- ventral proximal displacement of distal fragment
Both: pain of wrist, edema, deformity, bruising, discoloration, aching pain at rest, worsened by movement
What nerve is most vulnerable in elbow dislocation
Ulnar
What nerve is most vulnerable in shoulder disloation
Axillary
What nerves are most vulnerable in traumatic injury of the forearm and wrist (2)
Median and radial
_________________develop in about 30% of patients with RA. They are granulomas consisting of a central necrotic area surrounded by palisaded histiocytic macrophages, all enveloped by lymphocytes, plasma cells, and fibroblasts.
Rheumatoid nodules.
_________ is the most common joint disorder. Symptom often present in the 40s and 50s and is nearly universal (although not always symptomatic) by age 80. Only half of patients with pathologic changes have symptoms.
Osteoarthritis
What are some early symptoms of rheumatoid arthritis?
Early symptoms may include fatigue, muscle pain, a low-grade fever, weight loss, and numbness and tingling in the hands. In some cases, these symptoms occur before joint pain or stiffness is noticeable.
Symptoms:
Stiffness, pain, redness, warmth to the touch, and swelling.
Joint stiffness is most bothersome in the morning and after being still for a period of time, persists > 1hr.
OA or RA?
RA
Pain is the earliest symptom, sometimes described as a deep ache. Pain is usually worsened by weight bearing and relieved by rest but can eventually become constant. Stiffness follows awakening or inactivity but lasts < 30 minutes and lessens with movement.
OA or RA?
OA
Which lab tests should you order if a patient is presenting with clinical symptoms of RA?
RA is a clinical diagnosis. Referral to a specialist should not be based on the results of lab tests if there are no clinical features suggesting RA. There are no tests that can reliably make the diagnosis of RA.
- If there are clinical features then the following lab tests may be useful for monitoring and ruling out other types of arthritis: CRP, ESR, RF, ANA, X-rays, joint aspiration.
*CRP is preferred test (covered by MSP).
What muscle group is innervated by the sciatic nerveÉ
Hamstrings (semi membranous, semitendinous, biceps femoris)
Back pain that is predominantly felt in the back/ buttock is likely due to what cause?
Choose 2: Disc pain, facet joint pain, compressed nerve pain, spinal stenosis
Disc pain or facet joint pain.
To differentiate: disc pain is worse with flexion, facet joint pain is worst with extension
Back pain that is predominantly felt in the legs is likely due to what cause?
Choose 2:Disc pain, facet joint pain, compressed nerve pain, spinal stenosis
Compressed nerve pain or spinal stenosis.
To differentiate: nerve pain hurts with all movements, whereas spinal stenosis is worse with walking/ standing and is improved with sitting/ flexion
Doug has back pain that is worse in his back than his legs and hurts the most with flexion. What pattern of back pain does this best fit?
Disc pain.
Karen has back pain that is worse in her low back and hurts the most with back extension. What pattern of back pain does this best fit?
Facet joint pain
Jim has back pain that radiates to his legs and feels the worst in his legs. It is constant and all movements hurt. What pattern of back pain does this best fit?
Compressed nerve pain
Sally has low back pain that feels worse in her legs and is intermittent. It is worse with walking and standing, and relieved with sitting/ flexion. What pattern of back pain does this best fit?
Spinal stenosis
When assessing back pain, what question is important to rule out cauda equina syndrome?
Asking about accidents with bowel/ bladder function, saddle anesthesia
When assessing back pain, what question is important to rule out inflammatory arthritis?
If age of onset <45, are you experiencing morning stiffness in your back more than 30 minutes?
NIFTI is used to rule out red flags and back pain. What does this stand for?
Neurological, infection, fracture, tumor, inflammation
When assessing back pain, what question should you ask to assess risk of developing pain chronicity?
Is there anything you can not do now that you could do before the onset of your back pain (see core back tool yellow flags)
6 important questions for back pain are….
(Core back tool)
1) where is your pain the worst?
2) is your pain intermittent or constant? (if constant- screen for red flags- NIFTI)
3) What typically increases your pain?
4) Is there anything you cant do not that you could before the pain? (if yes- screen for yellow flags)
5) Have you had any unexpected accidents with your bowel or bladder function since this episode of your low back pain started? (if yes- r/o cauda equina)
6) If age of onset <45, are you experiencing morning stiffness in your back > 30 min?
What is ankylosing spondylitis?
Chronic autoimmune inflammatory disease characterized by stiffening/ fusion of primarily the axial spine and sacroiliac joint with excessiv ebone formation
Main characteristics of ankylosing spondylitis
Typically diagnosed under 40 years old
Autoimmune- inflammation, fibrous scar tissue turns to ossified scar tissue, leading to joint fusion
Occurs at entheses (insertion sites of ligaments/ tensons on bone)
Develop lordosis, kyphosis
Extra skeletal manifestations (IBD, uveitis, lung fibrosis, achilles tendonitis, etc)
Back pain is low back, stiffness, constant, inflammatory in nature, progressive. May have dactylitis.
Labs- elevated ESR, CRP, bamboo sign on spine, sacroilitis.
Define spondylosis
Degeneration and flattening of intervertebral discs
(is like osteoarthritis of the spine)
Define spondylolisthesis
Forward shift of one disc on another (slipped disc); usually L5-S1
What areas of the spine do you most often see disc herniation?
Most affected lumbosacral discs are L4-L5 and L5-S1.
The most affected cervical region is C5-C6 and C6-C7.
Lumbar disc herniation is more common than cervical disc herniation.
What exactly is happening with disc herniation?
It is caused by the displacement of the nucleus pulposus or annulus fibrosus beyond the intervertebral disc space.
The nucleus pulposus is hydrated and acts a “shock absorber” by compressing when lifting a load and relaxing when load is removed.
With age nucleus pulposus weakens, becomes less dehydrated and more gelatinous –> more of the compression forces transferred to the annulus fibrosus. Overtime, the compression-relaxation cycle causes peripheral tears of the annulus fibrosus. The tear allows the nucleus pulposus to bulge and protrude through the annulus fibrosus and this can compress the nerve root.
What is the annulus fibrosis?
The annulus fibrosus is the strong wrapping that makes up the outside portion of the intervertebral disc. Its job is to contain and protect the soft material located in the center of the disc. This soft center is called the nucleus pulposus.
Most common causes of disc herniation?
Most commn = degenerative process as we age
2nd most common = trauma
In which direction does the herniation most often occur?
Most disc herniations occur in the posteolateral direction where the annulous fibrous is thinner and is not well supported by the anterior or posterior longitudinal ligaments
(posterolateral = back toward the spinal cord and off to the side)
What causes the pain in disc herniation?
The combination of nerve root compression and release of local inflammatory cytokines causes localized back pain.
Herniation in what area could lead to cauda equina syndrome
Multiple nerve root compressions may be found at the L5-S1 level affecting the cauda equina and leading to the cauda equina syndrome.
Is aggressive treatment usually necessary for herniated discs? What are the usual treatments?
“Over 85% of patients with symptoms associated with an acute herniated disc will resolve within 8 to 12 weeks without any specific treatments.”
Most herniated disc resolve on their own and do not require surgery.
Conservative treatments include NSAIDs, acetaminophen, therapeutic massage and physical therapy.
May require neurosurgery consultation.
S&S of disc herniation
The location and size of the herniation into the spinal canal and amount of space in the canal determine clinical signs. It causes radiculopathy or pinched nerve - injury to nerve roots in the area where they leave the spine.
Radiation of the pain follows distribution of the compressed nerve root. Lumbosacral area causes pain in the sacroiliac joint, buttocks, hip, posterior thigh, and leg. Cervical disc herniation causes shoulder and upper limb pain and hand. Pain increases with movements and straining. Range of motion is decreased in the lumbar spine or neck.
Numbness, tingling, decreased sensation, decreased range of motion and motor weakness of the extremities may occur along the path of the nerve root.
What diagnostic might we do for herniated disc? What is the significant of leg raise tests here? Which leg raise tests is highly SPECIFIC for herniation? Which is more SENSITIVE?
X-rays, CT-scans and MRI.
MRI is the most sensitive and preferred method if disc herniation is suspected.
CT myelography can be used to visualize herniated discs if patients are unable to do MRI.
The Straight Leg Raise (SLR) test is a commonly used test to identify an impairment in disc pathology or nerve root irritation. It have also specific importance in detecting disc herniation and neural compression.
The straight leg raise test is more sensitive but less specific than the contralateral straight leg raise for the diagnosis of radiculopathy due to disc herniation [40]. It is most helpful in the evaluation of radiculopathy at the L5 and S1 levels. Contralateral leg raise test is relatively specific for radiculopathy due to disc herniation, but has poor sensitivity
Straight leg test - how is it done?
The straight leg raise test: With the patient lying supine, the examiner slowly elevates the patient’s leg at an increasing angle, while keeping the leg straight at the knee joint (movement must be PASSIVE). The test is positive if it reproduces the patient’s typical pain and paraesthesia.
The contralateral (crossed) straight leg raise test: As in the straight leg raise test, the patient is lying supine, and the examiner elevates the asymptomatic leg. The test is positive if the maneuver reproduces the patient’s typical pain and paraesthesia.
What is radiculopathy?
= pinched nerve in the spine
Are males or females more likely to be diagnosed with Ankylosing Spondylitis?
Men are three times more likely
What is the peak age of incidence of Ankylosing Spondylitis?
Age 20 peak start of symptoms. Although often delay in diagnosis
Enthesis =
insertion site of ligaments and tendons on bones
What classically relieves pain related to Ankylosing Spondylitis?
Pain is usually improved by activity and aggravated by rest
Have stiffness in the morning
What symptoms do you often see as the onset of ankylosing spondylitis?
Gradual onset of low back pain and stiffness during early 20’s
Pain starts as insidious, becomes persistent. Worse with prolonged rest, improved by physical activity
Radicular (nerve) pain will have a ____ (positive/negative) straight leg raise
Positive
In addition to the leg raise tests, we can get clients to squat, heel walk, and toe walk to assess for disc herniation. Which nerve compression are we testing for each?
Squat = L4
Heel walk = L5
Toe walk = S1
Is pain in the lower back alone indicative of a positive straight leg test?
NO, need to see pain in the lower leg (below knee) to be truly positive.
Pain occurs when hip is flexed at 30 and 60 or 70 degrees from horizontal.
What is the most common cause of lumbar spinal stenosis?
1: Spondylosis
- Spondylolisthesis, trauma, paget disease of the bone (or other skeletal disease)
- Acquired: dwarfism, spina bifida, etc
What is spinal stenosis?
Spinal stenosis is a narrowing of the spinal canal that causes pressure on the spinal nerves or cord and
can be congenital or acquired (more common) and associated with trauma or arthritis.
Basically I understand it as any condition that encroaches on the spinal cord or spinal nerves
Is it always the central canal (where the spinal cord goes through) that’s most affected in spinal stenosis?
No, cause be narrowing of the central canal, lateral recess, or neural foramen (where the spinal nerve passes through)
What is the hallmark sign of lumbar spinal stenosis?
Neurogenic (or pseudo) claudication is a hallmark of LSS [1]. This is the tendency for symptoms, usually pain, to be exacerbated with walking, standing, and/or maintaining certain postures, and relieved with sitting or lying
Many patients with LSS are symptomatic only when active
