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joint Pain Flashcards

1
Q

Joint

A

. Junction/ union of 2+ bones of body
. Provides motion and flexibility to frame of body
.

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2
Q

Osteoarthritis grade 0

A

. Early stage
. No evident sclerosis
. Thin sub Honduras bone plate and trabeculae
. Articular cartilage connected to bone has fenestrae

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3
Q

Osteoarthritis grade 1

A

. Some subchondral clerosis and bone volume is inc.
. Thickened bone trabeculae
. Cartilage still contacts bone marrow

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4
Q

Osteoarthritis grade 2

A

. Distinct inc. in subchondral sclerosis and bone volume
. Fibrillation seen in subchondral bone pale
. No contact of bone marrow to articular cartilage

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5
Q

Osteoarthritis grade 3

A

. Late stage
. Severe subchondral sclerosis and massively inc. bone volume
. Bone marrow distance from cartilage inc.
. Subchondral bone plate flattens

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6
Q

Osteoarthritis

A

. Inflammatory infiltration
. Stromal activation
. Synovial lining hyperplasia

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7
Q

Risk factors for osteoarthritis

A 
. Over 40 
. Female 
. Prior injury to joint in question 
. Obesity 
. Repetitive use 
. High impact sports 
. Family history
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8
Q

Important part of physical and history w/ osteoarthritis

A

. 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)

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9
Q

Osteoarthritis non-pharmacological therapy

A

. Weight loss when weight bearing joints involved
. Exercise
. Ice
. OMT
. Chondroitin
. Na hyaluronate intra-articular injection
. Braces, canes

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10
Q

Osteoarthritis pharmacological therapy

A

. Non-steroidal anti-inflammatory drugs most effective
. Acetaminophen
. Corticosteroid injection (short-term)
. Opioids

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11
Q

Septic arthritis

A

. 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

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12
Q

Septic arthritis mortality rate

A

Up to 20% for elderly, immunocompromised

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13
Q

Septic arthritis risk factors

A

. 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

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14
Q

Septic arthritis microbial causes

A

. Staphylococcus aureus most common
. Gonorrhea in infants and adults w/ STD risk
. Strep

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15
Q

Septic arthritis common physical exam and history findings

A 
. May have fever 
. Recent joint surgery 
. Joint pain w/ ROM 
. STD exposure 
. Joint swelling, redness, warmth 
. Mono articular (knee most common)
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16
Q

Septic arthritis labs to complete

A

. 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

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17
Q

Septic arthritis

A

. Drain pus

. Empiric IV antibiotic therapy, switch to definitive antibiotic once lab results come in

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18
Q

Gout

A

. 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

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19
Q

Gout risk factors

A

. 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

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20
Q

Gout history and physical findings

A

. 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

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21
Q

Gout diagnostic tests

A

. 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)

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22
Q

Gout non-pharmacologic treatment

A

. 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

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23
Q

Gout pharmacologic treatment

A

. During attacks: NSAIDS, colchicine, corticosteroids

. Prevention: xanthine oxidase inhibitor, colchicine, probenecid, keeping uric acid serum level less than 6

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24
Q

Gout goals of treatments

A

. Keep serum uric acid in normal ranges

. Keep arracks to minimum to improve quality of life and limit joint damage

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25
Q

Tendons

A

. 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

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26
Q

Bursae

A

. Sac-like structures
. Lined by synovial membrane that provide cushioning btw bones, tendons, and muscles
. Contains synovial fluid
. Can communicate w/ adjacent joint space

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27
Q

Rotator cuff tendons and muscles

A

. Supraspinatus
. Subscapularis
. Teres minor
. Infraspinatus

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28
Q

Tendinopathy

A

. 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

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29
Q

Bursitis

A

. Inflammation, edema of bursa
. Result of injury
. Occurs along w/ tendinopathy
. Olecranon bursitis, subacromial bursitis (examples)

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30
Q

Rotator cuff tendinopathy

A

. 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

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31
Q

Steps of rotator cuff tendinopathy

A

. 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)

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32
Q

History and physical exam findings in rotator cuff tendinopathy

A

. 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

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33
Q

Diagnostic testing for rotator cuff tendinopathy

A

. Ultrasound or MRI when in doubt, otherwise not necessary

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34
Q

Non-pharmacologic treatment of rotator cuff tendinopathy

A 
. OMT 
. Heat
. Brief rest, early rehab
. ROM and strengthening exercises 
. Needling/fenestation of tendon 
. Surgery (poor evidence supporting this)
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35
Q

Pharmacologic treatment for rotator cuff tendinopathy

A

. NSAIDS

. Corticosteroids in subacromial space

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36
Q

Prevention for rotator cuff tendinopathy

A

. Balanced strength of rotator cuff group vs pectoral muscles
. Good posture
. Stabilization of scapulae

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37
Q

T/F Sodium urate crystals are negative birefringement w/ needle shape

A

T

38
Q

Osteoporosis and osteopenia

A

. 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

39
Q

Osteoporosis type 1 and 2

A

. 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

40
Q

Bone physiology

A

. 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

41
Q

Osteoporosis risk factors

A 
. 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
42
Q

Osteoporosis symptoms

A

. Chronic, progressive joint and bone pain

. Sudden onset severe pain when bone fractures

43
Q

Osteoporosis diagnosis

A

. 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)

44
Q

Osteoporosis pharmacologic treatment

A

. Bisphosphonate (prevents femoral and vertebral fractures)
. Calcitonin (prevents vertebral fractures)
. Terapeptide (prevents vertebral fractures)
. Estrogen therapy (prevents femoral fractures)
. Bisphosphonate or terapeptide best treatments

45
Q

Non-pharmacologic treatment for osteoporosis

A 
. 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
46
Q

Osteoporosis prevention

A

. DEXA at regular intervals
. Vit. D and Ca supplements
. Something cessation
. Limited alcohol use

47
Q

T/F patients w/ hip fracture in nursing homes have high rate of death in first year after fracture

A

T

48
Q

Bone changes in osteoporosis

A

. Dec. in bone mass w/ dec. density and enlargement of bone spaces
. Produces porosity and fragility

49
Q

Bone changes in osteopenia

A

. Reduction in bone volume to below normal levels

. Due to inadequate replacement of bone lost to normal lysis

50
Q

Percentage of adults over 50 that have osteoporosis

A

. 9% (usually at femoral neck or lumbar spine (11% women, 9% men)

51
Q

Percentage of post-menopausal women w/ osteoporosis

A

50%
. 25% develop vertebral deformities
. 15% suffer hip fractures

52
Q

Diseases associated with osteoporosis

A 
. Hyperthyroidism 
. Celiac sprue
. Lupus 
. RA
. Cirrhosis 
. Chronic kidney disease
. DM 
. HIV
. Hypodonadism
. Anorexia nervosa
. Hyperparathyroidism
53
Q

Antacids that contain aluminum are used for ___

A

Heartburn

54
Q

Cyclosporine and tacrolimus is used for what?

A

Preventing rejection of organ transplant

55
Q

Heparin used for what?

A

. Preventing blood clots

56
Q

Loop diuretics (furosemide and torsemide) used what what?

A

HF, edema, Kidney problems

57
Q

Medroxyprogesterone acetate used for what?

A

Contraception

58
Q

Methotrexate used for??

A

Cancer and RA

59
Q

Thiazolidinediones (pioglitazone and rosiglitazone) used for what?

A

. DM

60
Q

Osteoporosis screening

A

. 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)

61
Q

FRAX calculator

A

. 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

62
Q

COnsider FDA approved medical therapies for osteoporosis based on following criteria _____

A

. 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

63
Q

What are possible options after osteoporosis screening?

A

. Determine if treatment is needed
. Counsel on fracture/fall prevention
. Lifestyle modifications
. Pharmacological treatment

64
Q

Calcium recommendations from institute of medicine (IOM)

A

. 1200 mg/day for postmenopausal women w/ osteoporosis
. All other adults 1000 mg/day
. Supplement if not getting it in diet

65
Q

Foods high in Ca

A 
. Tofu w/ Ca 
. Cheese
. Yogurt 
. Milk 
. Orange juice w/ Ca 
. Soy milk
66
Q

Vitamin. D recommendations

A

. 800 IU inn diet for postmenopausal women w/ osteoporosis
. 600 IU for other adults
. Supplementation is recommended

67
Q

Foods high in Vit. D

A 
. Cod liver oil 
. Salim 
. Mushrooms 
. Mackerel 
. Tuna fish 
. Milk
68
Q

Shoulder girdle ROM

A

. abduction/adduction
. External/internal rotation
. Extension/flexion

69
Q

Primary muscles of shoulder

A

. Rotator cuff (Supra/infraspinatus, teres minor, subscapularis), all do ER except supraspinatus does abduction
. Deltoid
. Trapezius

70
Q

How to complete shoulder examination

A

. 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

71
Q

Shoulder impingement

A

. 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
.

72
Q

Progression of problems w/ shoulder impingement.

A

. Impingement -> Subacromial bursitis -> orator cuff tendonitis -> rotator cuff tear

73
Q

What are hawkin’s and neer’s tests doing with the bones while test is performed?

A

. Pressing greater tuberosity of humerus against acromion

74
Q

Subscapularis tendinopathy test

A

. Internal rotator

. Lift off sign (hand behind back push out against resistance)

75
Q

Infraspinatus/teres minor tendinopathy test

A

. external rotator

. Rotate arm out against resistant w/o moving elbow

76
Q

Supraspinatus test

A

. Empty can sign

. Dump out position, push down from above

77
Q

Rotator cuff tear

A

. 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

78
Q

Shoulder dislocations

A 
. 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
79
Q

ElbowForearm joints and motions

A

. Humeroulnar: fl/extension, can ab/dduct
. Humeroradial: sup/pronation
. Prox. Radioulnar: sup/pronation

80
Q

Primary flexors and extensors of elbow origin

A

. Flexors: on/near medial epicondyle of humerus

. Extensors: lat. epicondyle (innervated by radial n.)

81
Q

Lateral epicondylitis

A

Tennis elbow

. Inflammation of extensors

82
Q

Golfer’s elbow

A

. Medial epicondylitis

. Inflammation of flexors

83
Q

Nursemaid’s elbow

A

. 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

84
Q

How to examine wrist and hand

A

. 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

85
Q

Wrist ROM

A

. Fl/extension

. Ulnar (abduction) and radial (adduction) deviation

86
Q

Fingers ROM

A

. Fl/extension, abduction. Adduction

87
Q

Thumb ROM

A

. Fl/extension
. Abduction (thumba way from palm)
. Adduction (thumb towards palm)
. Opposition ( thumb touches finger)

88
Q

Scaphoid fracture

A

. FOOSH injury
. Tender at anatomic snuffbox
. Diagnose: X-ray, CT/MRI if clinically suspicious
. Treat: surgery, can cause avascular necrosis if you wait

89
Q

Carpel tunnel syndrome

A

. 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)

90
Q

Carpel tunnel syndrome physical exam

A

. 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

91
Q

De Quervains tenosynovitis

A

. 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)

92
Q

What is RICE treatment?

A

. Rest
. Ice
. Compress
. Elevate

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