joint Pain Flashcards
Joint
. Junction/ union of 2+ bones of body
. Provides motion and flexibility to frame of body
.
Osteoarthritis grade 0
. Early stage
. No evident sclerosis
. Thin sub Honduras bone plate and trabeculae
. Articular cartilage connected to bone has fenestrae
Osteoarthritis grade 1
. Some subchondral clerosis and bone volume is inc.
. Thickened bone trabeculae
. Cartilage still contacts bone marrow
Osteoarthritis grade 2
. Distinct inc. in subchondral sclerosis and bone volume
. Fibrillation seen in subchondral bone pale
. No contact of bone marrow to articular cartilage
Osteoarthritis grade 3
. Late stage
. Severe subchondral sclerosis and massively inc. bone volume
. Bone marrow distance from cartilage inc.
. Subchondral bone plate flattens
Osteoarthritis
. Inflammatory infiltration
. Stromal activation
. Synovial lining hyperplasia
Risk factors for osteoarthritis
. Over 40 . Female . Prior injury to joint in question . Obesity . Repetitive use . High impact sports . Family history
Important part of physical and history w/ osteoarthritis
. Chronic pain that may wax and wane
. 1 joint, but can be more
. Pain worse w/ activity, improves w/ rest
. Dec. joint ROM due to pain
. Joint swelling and tenderness
. DOES NOT have fever, Chills, weight loss, vision changes
. Crepitus (clicking/popping noise when ROM is performed)
Osteoarthritis non-pharmacological therapy
. Weight loss when weight bearing joints involved
. Exercise
. Ice
. OMT
. Chondroitin
. Na hyaluronate intra-articular injection
. Braces, canes
Osteoarthritis pharmacological therapy
. Non-steroidal anti-inflammatory drugs most effective
. Acetaminophen
. Corticosteroid injection (short-term)
. Opioids
Septic arthritis
. Microbial invasion of joint space causing inflammatory response and joint destruction
. Less than 15 y/0 and over 55 common
. Causes by previous infection
. Gets into joint because synovial lining lacks basement membrane
. Can happen following joint trauma
Septic arthritis mortality rate
Up to 20% for elderly, immunocompromised
Septic arthritis risk factors
. Systemic illnesses (immunosuppression, HIV, DM, alcoholism, sickle cell)
. Joint disorders (RA, prosthetic joints)
. Advanced age
. IV drudge abuse
. High risk sexual behaviors
. 22% patients have no risk factors
Septic arthritis microbial causes
. Staphylococcus aureus most common
. Gonorrhea in infants and adults w/ STD risk
. Strep
Septic arthritis common physical exam and history findings
. May have fever . Recent joint surgery . Joint pain w/ ROM . STD exposure . Joint swelling, redness, warmth . Mono articular (knee most common)
Septic arthritis labs to complete
. CBC (most helpful in pediatric patients)
. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) (helpful in peds)
. Synovial fluid stain, culture, or analysis
. Blood culture
. STD testing
Septic arthritis
. Drain pus
. Empiric IV antibiotic therapy, switch to definitive antibiotic once lab results come in
Gout
. Uric acid crystals
. Causes inflammatory response
. Occurs (90%) when people under excrete uric acid in urine (chronic kidney disease, dehydration, meds)
. Can also occur (10%) when people overproduce uric acid (high purine diet, obesity, alcohol use, metabolic disorder)
. Cause joint damage every time they occur
Gout risk factors
. Men over 30, post menopausal women
. More common in African Americans
. Obesity
. DM, hypertension, hyperlipidemia
. High purine or high fructose corn syrup diet
. Alcohol consumption
. Myeloproliferative (blood cell formation) disorders
Gout history and physical findings
. May have chills or fever
. Sudden onset joint pain
. Excruciating, tender to touch
. Inability to bear weight in lower extremity involve
. 1st toe joint commonly affected
. Significant redness and edema of affected joint
. Tophi (subQ nodules made of crystals) in patients with gou for 10+ yrs and multiple attacks
Gout diagnostic tests
. CBC (white count high)
. Serum uric acid (look for change in level, not if it is elevated or not)
. Synovial fluid analysis (neg. for organisms)
. Monosodium urate crystals in synovial fluid (84% sensitivity, 100% specificity)
. Tophi confirmed by aspiration (30% sensitive, 99% specific)
Gout non-pharmacologic treatment
. Ice joint during attack
. Heat may help
. Vit. C supplements
. Enriched skim milk powder w/ anti-inflammatory peptides
. Low purine diet, no beer
. Avoiding sudden diet changes
. All of these have not been studied or have poor evidence
Gout pharmacologic treatment
. During attacks: NSAIDS, colchicine, corticosteroids
. Prevention: xanthine oxidase inhibitor, colchicine, probenecid, keeping uric acid serum level less than 6
Gout goals of treatments
. Keep serum uric acid in normal ranges
. Keep arracks to minimum to improve quality of life and limit joint damage
Tendons
. Bundles of collagen fibers interwoven w/ muscle
. Serves as anchors to bone for muscles at point of origin and insertion
. Strong, elastic
. Low oxygen demand
Bursae
. Sac-like structures
. Lined by synovial membrane that provide cushioning btw bones, tendons, and muscles
. Contains synovial fluid
. Can communicate w/ adjacent joint space
Rotator cuff tendons and muscles
. Supraspinatus
. Subscapularis
. Teres minor
. Infraspinatus
Tendinopathy
. Degeneration, delayed healing, abnormal thickening of tendon as result of injury
. Injury from overuse, microtears, trauma
. Occurs at tendon-periosteum junction
. Examples: rotator cuff tendinopathy, tennis elbow
Bursitis
. Inflammation, edema of bursa
. Result of injury
. Occurs along w/ tendinopathy
. Olecranon bursitis, subacromial bursitis (examples)
Rotator cuff tendinopathy
. Over 30, but can be any age
. Overhand/throwing sports, repetitive overhead tasks (middle age), and degeneration of tendon (old)
. Acute shoulder symptoms w/ patient-identifiable cause or insidious onset w/o patient-identifiable cause
Steps of rotator cuff tendinopathy
. Step 1: small cuff tears from repetitive use injury
. Step 2: tendon scarring and thickening
. Step 3: secondary irritation of overlying bursa
. Step 4: thickened tendon and bursa (dec. sub-acromegaly space)
. Step 5: impingement pain and crepitus (provoked w/ abduction)
History and physical exam findings in rotator cuff tendinopathy
. Active ROM pain
. Pain when lying on ipsilateral side
. Mild weakness w/ shoulder abduction be 60-120 degrees
. May have numbness/tingling in fingers
. Anterolateral shoulder pain
. Inc. internal rotation of ipsilateral glenohumeral joint
. Myofascial restrictions thoracic region
Diagnostic testing for rotator cuff tendinopathy
. Ultrasound or MRI when in doubt, otherwise not necessary
Non-pharmacologic treatment of rotator cuff tendinopathy
. OMT . Heat . Brief rest, early rehab . ROM and strengthening exercises . Needling/fenestation of tendon . Surgery (poor evidence supporting this)
Pharmacologic treatment for rotator cuff tendinopathy
. NSAIDS
. Corticosteroids in subacromial space
Prevention for rotator cuff tendinopathy
. Balanced strength of rotator cuff group vs pectoral muscles
. Good posture
. Stabilization of scapulae
T/F Sodium urate crystals are negative birefringement w/ needle shape
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Osteoporosis and osteopenia
. Progressive loss of protein/minerals in bone (mild loss is osteopenia, severe loss in osteoporosis)
. Hypogonadism causes inc. osteoclasts activity
. Aging causes dec. osteoblasts activity
. Bones weaken to point of fracturing
. Effects trabecular and cortical bone
Osteoporosis type 1 and 2
. Type 1: post-menopausal women, trabecular bone effected, fractures occur in vertebrae and distal forearm
. Type 2: men and women over 60, trabecular and cortical bone effected, fractures occur in femoral neck and proximal humerus
Bone physiology
. Remodeling occurs due to micro fractures from everyday wear and tear
. Peak bone mass 25-35
. Loss of bone mass 1% per year after that
. 90% of women have osteoporosis at age 80, 50% men have it at 80
Osteoporosis risk factors
. Women . BMI under 22 . Northern European, Asian descent . Parent history of osteoporosis . Lack of exercise . Tobacco use . Heavy alcohol use . Low Ca intake/absorption . Low vit. D/ lack of sun
Osteoporosis symptoms
. Chronic, progressive joint and bone pain
. Sudden onset severe pain when bone fractures
Osteoporosis diagnosis
. Loss of height (1.5” since 25)
. Dec. bone density on X-ray
.. abnormal DEXA
. Osteopenia: T or Z score 1-2.5 SD below mean calculated by average bone density in pre-menopausal women
. Osteoporosis: T/Z score over 2.5 SD from mean
. Blood work (Ca, CBC, PTH)
Osteoporosis pharmacologic treatment
. Bisphosphonate (prevents femoral and vertebral fractures)
. Calcitonin (prevents vertebral fractures)
. Terapeptide (prevents vertebral fractures)
. Estrogen therapy (prevents femoral fractures)
. Bisphosphonate or terapeptide best treatments
Non-pharmacologic treatment for osteoporosis
. Surgical repair for femoral fracture . Smoking cessation . Limited alcohol intake . OMT for pain control . No good surgery for vertebral fracture . Vit. D supplements . Ca supplements . Weight bearing exercises . Balance exercises to prevent falls
Osteoporosis prevention
. DEXA at regular intervals
. Vit. D and Ca supplements
. Something cessation
. Limited alcohol use
T/F patients w/ hip fracture in nursing homes have high rate of death in first year after fracture
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Bone changes in osteoporosis
. Dec. in bone mass w/ dec. density and enlargement of bone spaces
. Produces porosity and fragility
Bone changes in osteopenia
. Reduction in bone volume to below normal levels
. Due to inadequate replacement of bone lost to normal lysis
Percentage of adults over 50 that have osteoporosis
. 9% (usually at femoral neck or lumbar spine (11% women, 9% men)
Percentage of post-menopausal women w/ osteoporosis
50%
. 25% develop vertebral deformities
. 15% suffer hip fractures
Diseases associated with osteoporosis
. Hyperthyroidism . Celiac sprue . Lupus . RA . Cirrhosis . Chronic kidney disease . DM . HIV . Hypodonadism . Anorexia nervosa . Hyperparathyroidism
Antacids that contain aluminum are used for ___
Heartburn
Cyclosporine and tacrolimus is used for what?
Preventing rejection of organ transplant
Heparin used for what?
. Preventing blood clots
Loop diuretics (furosemide and torsemide) used what what?
HF, edema, Kidney problems
Medroxyprogesterone acetate used for what?
Contraception
Methotrexate used for??
Cancer and RA
Thiazolidinediones (pioglitazone and rosiglitazone) used for what?
. DM
Osteoporosis screening
. Prevents debilitating fractures
. Screen women 65 or older
. Screen women younger than 65 who are postmenopausal w/ modifiable risk factor
. Screen via DEXA scan that measures bone density (T score -1 to +1 normal, -1 to -2.5 osteopenia, less than -2.5 is osteoporosis)
FRAX calculator
. Fracture assessment risk
. People w/ osteopenia but have risk factors undergo this calculation
. Consider treatment is fracture risk is over 3% in 10 yrs or 20% chance of major osteoporotic fracture
COnsider FDA approved medical therapies for osteoporosis based on following criteria _____
. Hip/vertebral fracture
. T score under -2.5 at femoral neck or spine
. Low bone mass and 10-yr probably of hip fracture over 3% or major fracture risk over 20%
. Clinician judgement and patient preferences
What are possible options after osteoporosis screening?
. Determine if treatment is needed
. Counsel on fracture/fall prevention
. Lifestyle modifications
. Pharmacological treatment
Calcium recommendations from institute of medicine (IOM)
. 1200 mg/day for postmenopausal women w/ osteoporosis
. All other adults 1000 mg/day
. Supplement if not getting it in diet
Foods high in Ca
. Tofu w/ Ca . Cheese . Yogurt . Milk . Orange juice w/ Ca . Soy milk
Vitamin. D recommendations
. 800 IU inn diet for postmenopausal women w/ osteoporosis
. 600 IU for other adults
. Supplementation is recommended
Foods high in Vit. D
. Cod liver oil . Salim . Mushrooms . Mackerel . Tuna fish . Milk
Shoulder girdle ROM
. abduction/adduction
. External/internal rotation
. Extension/flexion
Primary muscles of shoulder
. Rotator cuff (Supra/infraspinatus, teres minor, subscapularis), all do ER except supraspinatus does abduction
. Deltoid
. Trapezius
How to complete shoulder examination
. Inspect for swelling, deformity, atrophy, abnormal positioning
. Palpate over bony landmarks and tender areas
. Check ROM
. Perform maneuvers to assess AC joint, overall shoulder rotation, and rotator cuff
Shoulder impingement
. Narrow space btw acriomion process of scapula and head of humerus
. Painful arc of motion
. To diagnose: pos. Hawkins, neers sign, weak ER w/ arm at side
.
Progression of problems w/ shoulder impingement.
. Impingement -> Subacromial bursitis -> orator cuff tendonitis -> rotator cuff tear
What are hawkin’s and neer’s tests doing with the bones while test is performed?
. Pressing greater tuberosity of humerus against acromion
Subscapularis tendinopathy test
. Internal rotator
. Lift off sign (hand behind back push out against resistance)
Infraspinatus/teres minor tendinopathy test
. external rotator
. Rotate arm out against resistant w/o moving elbow
Supraspinatus test
. Empty can sign
. Dump out position, push down from above
Rotator cuff tear
. Partial or full thickness
. Repetitive stress/age/throwing/rowing/weight lifting/occupational
. Most from chronic wearing down over time
. Diagnose via MRI/US/CT
. Treatment: PT to surgical repair
Shoulder dislocations
. 95% ant. . Post. Dislocation subtle in elderly . Inf. Rare (from hyperabduction) . Symptoms: pain, inability to move shoulder, numbness . Diagnose: x-ray scapular y view . Treat: reduction w/ traction
ElbowForearm joints and motions
. Humeroulnar: fl/extension, can ab/dduct
. Humeroradial: sup/pronation
. Prox. Radioulnar: sup/pronation
Primary flexors and extensors of elbow origin
. Flexors: on/near medial epicondyle of humerus
. Extensors: lat. epicondyle (innervated by radial n.)
Lateral epicondylitis
Tennis elbow
. Inflammation of extensors
Golfer’s elbow
. Medial epicondylitis
. Inflammation of flexors
Nursemaid’s elbow
. Radial head subluxation due to annular ligament tear
. Pull on pronates forearm is cause
. Presentation: not painful, refuse to use arm, held in pronation and slightly flexed, no swelling, may be holding wrist
. Reduction: pressure over radial head, supination or pronation w/ flexion, extension/hyperpronation
. Only get X-rays if history and exam are not consistent
How to examine wrist and hand
. Inspect: moothness of motion, surface contour, alignment of wrist/fingers, bony deformities
. Palpate: all bones for swelling/tenderness, anatomic snuffbox (distal to radial sytloid process w/ lat. extension of thumb away from hand, big in scaphoid fracture)
. Check ROM
. Test hand grip strength
. Test sensation on palmar and dorsal surfaces
Wrist ROM
. Fl/extension
. Ulnar (abduction) and radial (adduction) deviation
Fingers ROM
. Fl/extension, abduction. Adduction
Thumb ROM
. Fl/extension
. Abduction (thumba way from palm)
. Adduction (thumb towards palm)
. Opposition ( thumb touches finger)
Scaphoid fracture
. FOOSH injury
. Tender at anatomic snuffbox
. Diagnose: X-ray, CT/MRI if clinically suspicious
. Treat: surgery, can cause avascular necrosis if you wait
Carpel tunnel syndrome
. Pain/numbness of 1st 3 fingers, not in palm, at night
. Loss of sensation in distribution of median nerve (palmar surface of 1-4 digits, dorsal surface thumb, distal part of fingers 2-4)
Carpel tunnel syndrome physical exam
. Weak abduction of thumb (most sensitive test)
. Tinel’s sign (tingling w/ tapping on median n.)
. Phalen’s sign ( pressing back of hands together in acute flexion for 60 s)
. Thenar eminence atrophy in severe cases
De Quervains tenosynovitis
. Thumb extensor tenosynovitis
. Assoc. w/ repetitive activities
. Happens more in males
. Affects abductor pollicus longus and extensor pollicus brevis
. Pain and swelling
. Test: finkelstein test ( thumb clasped and wrist forced into ulnar deviation)
What is RICE treatment?
. Rest
. Ice
. Compress
. Elevate
