MSK Flashcards
Osteoporosis Risk Factors
Postmenopausal women age >50 thin low dietary calcium Vitamin D deficient Tobacco or alcohol use use of corticosteroids
Calcium recomendations
Men 50-70 : 1000mg/day
Women >50: 1200 mg/day
Vitamin D recomendations
All adults >50: 800-1000 units/day
Osteoporosis Screening Recomendations
All women >50
Younger women with risk factors
Men with risk factors
Inflammatory vs Non inflammatory pain
Inflammatory - red and warm
Non-inflammatory - cool to touch, edema or swelling around joint without warmth
Lupus
Autoimmune disorder
Joint pain with butterfly rash on the face
Psoriatic arthritics
Autoimmune disorder
Joint pain with scaly rash on elbows and pitting nails
Lyme
Infection
Joint pain with “bullseye rash” - expanding erythematous patch
Mental status changes, facial weakness or stiff neck indicate CNS involvement.
Serum sickness
Joint pain with hives
Reiter’s syndrome
Genetic disorder
Joint pain with erosion or scaling on the penis and crusted scaling papules on the soles and palms.
Red, burning, itchy eyes.
Gonococci arthritis
Infectious process
Joint pain with papules, pustules or vesicles with red base on extremities.
May start with a sore throat.
Ulcerative Colitis and Sclerodermaa
Joint pain with diarrhea, abd pain and cramping
Types of Swelling
Synovial membrane may feel boggy
Effusion from excess synovial fluid in joint or swelling
Soft-tissue structures like bursae, tendons, tendon sheaths
Muscle Strength Rankings
0 = no contraction, complete paralysis
1= slight contraction but severe weakness, extremity doesn’t move
2 = Full passive ROM
3= Full ROM with gravity but not against resistance
4=Full ROM with gravity and with some resistance
5= Full ROM, normal finding
Examination of TMJ (inspection, palpation, ROM)
Inspection-Facial symmetry
TMJ swelling or redness
Palpation - Muscles of Mastication
ROM - Open and close, protrusion and retraction, side to side
3 landmarks of the shoulder
A - Acromian process
B - Coracoid process
C - Greater tubercle
ROM of shoulder
Flexion, extension, abduction, adduction internal rotation (hands behind small of back) and external rotation (hands behind neck)
Apley Test
Touch opposite scapula over shoulder and around the back. Difficulty suggests rotator cuff problem or adhesive capsuilitis
Neer’s Test
Press scapula and raise patient’s arm on same side.
Difficulty is a + and indicates rotator cuff inflammation or tear
Hawkin’s Test
Flex patient’s shoulder and elbow 90degrees palm down. Rotate arm internally. Pain is + for inflammation or tear of rotator cuff
6 Tests for Rotator Cuff Injury
Apley Test Neer's Test, Hawkin's Test "Empty Can" Test Forearm supination Drop arm test
Suprapinatus “Empty Can” Test
Elevate pt’s arms, point their thumbs down, apply pressure. Weakness is + and indicates rotator cuff tear
Forearm Supination test
Flex forearm to 90 degrees at elbow and pronate wrist. Provide pressure as patient tries to supinate. Pain is + for inflammation at head of biceps tendon or rotator cuff gear
Drop Arm Test
Abduct arm to shoulder level. Ask pt to lower slowly as you tap it. If arm just drops, + for rotator cuff tear
Aprehension Test
Externally rotate shoulder with elbow bent. + patient becomes apprehensive. Indicates dislocated shoulder
What are common/concerning symptoms?
Low back pain Neck pain Monoarticular/polyarticular joint pain Joint pain with systemic features Joint pain associated with symptoms from another organ system
Acute Rheumatic fever
Sore throat that precedes joint pain
What would crepitus sound like upon palpation?
Rice crispy sound over joints
What is rotator cuff tendinitis?
- Caused by overuse or injury
- common in young adults and middle aged athletes
- minor pain with activity and rest
- pain from front of shoulder to side of arm
- sudden pain with lifting/reaching movements
- tenderness below the acromion
What is a dislocated shoulder?
- shoulder instability from anterior dislocation of the humerus. Joint “slipped out”
- positive apprehension test
- pain from any shoulder movement
- rounded edge of lateral aspect of shoulder appears flattened
What is a rotator cuff tear?
- injury from fall or repeated impingement
- partial or complete tear, usually after 40yrs
- weakness, atrophy, pain and tenderness of supraspinatus and infraspinatus muscles
- positive drop arm test- will shrug to lift shoulder
What is adhesive capsulitis?
- frozen shoulder
- fibrosis of glenohumeral joint capsule, fibrosis builds up from overuse
- diffuse, dull, aching pain
- progressive restriction of activity/passive range of motion
- no localized tenderness (is diffuse)
- unilateral
- usually 50-70 years old
- antecedent painful disorder of the shoulder, that has decreased shoulder movement
What is acromioclavicular arthritis?
- From prior injury, results in a degenerative change in the joint
- common
- pain with abduction
- tenderness localized to the AC joint
ROM of elbow
Flex and extend elbow
Pronate and supinate hand
What is olecranon bursitis?
- swelling and inflammation of the olecranon bursa
- from trauma, rheumatoid arthritis, gouty arthritis
- If RA: warm, balloon filled w/ water
- If gout: will feel the crystals
- swelling is superficial to the olecranon process
- no pain/discomfort
What is arthritis?
- synovial inflammation or fluid felt b/w olecranon process and epicondyles
- boggy, soft, fluctuant swelling, tender
- Causes: rheumatoid, gout, osteoarthritis, trauma
- pain, stiffness, restricted movement
What are rheumatoid nodules?
- subcutaneous nodules along pressure points on exterior ulnar surface
- seen in rheumatoid arthritis and acute rheumatic fever patients
- firm, non-tender, fixed
- located more distally from the olecranon bursa
What is lateral epicondylitis?
- tennis elbow, common
- pain with extension of the elbow, esp. against resistance
- tender 1cm distal to the lateral epicondyle
- from repetitive extension of wrist or forearm pronation-supination
What is medial epicondylitis?
- pitcher/golfers elbow
- pain with flexion, esp. against resistance
- tender lateral and distal to medial epicondyle
- from repetitive wrist flexion, like throwing
ROM of wrist
flexion
extension
ulnar abduction
radial adduction
ROM of fingers
flexion
extension
abduction (fingers spread apart)
adduction (finger back together
ROM of thumb
flexion extension abduction (thumb moves away from palm) adduction (thumb moves towards palm) opposition (thumb touches each finger)
What is carpal tunnel syndrome?
- pain/numbness of first 3 fingers (but not palm), esp. at night
- loss of sensation in distribution of the medial nerve
- Signs: weak abduction of the thumb (thenar wasting) , Tinel’s sign (tapping), Phalen’s sign (flexing)
Tinel’s sign
tingling with tapping over the median nerve as it enters the carpal tunnel
Phalen’s sign
numbness or tingling with pressing the back of the hands together in acute flexion for 60 seconds
De Quervan’s Tenosynovitis
- pain with palpation over the tendon sheath of the thumb
- may see swelling
- more common in women 3-4 weeks after pregnancy
- Test: Finklestein test
What is the Finklestein test?
- make a fist with thumb enclosed and flex wrist
- tenderness along the outer edge of wrist is positive
What is Dupuytren’s Contracture?
- thickened plaque overlying the flexor tendon on the ring finger at the palmar crease level
- skin in the area puckers and thickened fibrotic cord develops between palm and finger
- flexion contractors may ensue
What is trigger finger?
- painless nodule in a flexor tendon in the palm, near the metacarpal head
- finger extends and flexes with a palpable and audible snap, as the nodule pops into the tendon sheath
ROM of neck
flexion- chin to chest
extension- look up to ceiling
rotation- look over the shoulder
lateral bending- ear to shoulder
ROM of spine
flexion- bend to touch toes
extension- bend backwards
rotation- rotate trunk
lateral bending- bend to side from waist
Mechanical neck pain
- aching pain of cervical paraspinal muscles/ligaments with movement
- spasm, stiffness, tightness in shoulder and upper back
- lasts weeks
- no radiation, paresthesia, weakness
- ROM- same
- may have headache
Whiplash neck pain
- aching paracervical pain and stiffness
- starts day after injury, can be chronic
- occipital headache, dizziness, malaise, fatigue
- from injury: forced hyperflexion/extension
- ROM- decreased
- perceived weakness of upper extremities
Cervical Radiculopathy
- sharp burning/tingling pain in neck/ one arm
- parasthesia and weakness in affected arm
- nerve root compression, usually C7
- from herniated disc
- weakness of triceps (if C7 involved) or biceps (if C6 involved)
Cervical Myelopathy
- cord compression EMERGENCY
- neck pain with bilateral weakness and paresthsia in upper and lower extremities
- hand clumsiness, urinary frequency
- from degenerative disc or cervical stenosis or trauma
- hyperreflexia, pos. Babinski, gait changes
- must immobilize neck immediately
What are red flags with back pain?
- over 50 years old
- hx cancer or IV drug use
- unexplained weight loss
- pain lasting longer than 1 month or not responding to treatment
- Pain at night or at rest (malignant pain)
- Presence of infection (fever, chills, malaise)
Mechanical low back pain
- aching pain in lumbar sacral area, may radiate to lower leg
- acute, idiopathic, benign, self-limiting
- worse with standing or twisting motion
- usually 30-50 years old and work related
- no motor or sensory impairment
Sciatica (Radicular low back pain)
- shooting pain below the knee with low back pain
- asso. with numbness and weakness
- bending, sitting, sneezing, coughing, straining worsens pain
- disc herniation, esp if calf muscle wasting
- negative straight leg test makes dx unlikely
Straight-leg test
- patient is supine, raise relaxed, straightened leg, flexing at the hip and then dorsiflex the foot
- will cause pain in pt. with a herniated disc
Lumbar spinal stenosis
- “pseudoclaudication” pain in back of legs with walking, improves with rest or lumbar flexion
- vague pain, usually bilateral in legs
- hypertrophic degenerative disease: thickening of ligament causing narrowing of spinal canal
- Common over 60 years
Chronic back stiffness: ankylosing spondylitis
- Chronic inflammatory disease
- Age onset
Chronic back stiffness: Diffuse idiopathic hyperostosis (DISH)
- Non-inflammatory disease
- Calcification and ossification of spinal ligaments
- Age onset >50
- Decreased range of spinal motion, particularly thoracic movement
What to consider if there is nocturnal back pain, unrelieved by rest?
metastatic malignancy
Cauda Equina Syndrome
- Low back pain associated with bladder symptoms, saddle anesthesia
- Compression of the spinal nerve root
- Surgical emergency as the compression is often caused by a tumor, ruptured disk, infection, fracture, or narrowing of the spinal canal
Sarcoilitis
- Lumbosacral pain radiates to the buttocks, groin or posterior thigh
- Aggravated by extensive use prolonged exercise
- PE: tenderness at SI joint
- Can be an overuse injury or related to systemic illnesses
ROM of Hip
Flexion Extension Abduction Adduction External and Internal Rotation
Bursitis
- an inflammation or degeneration of the sac-like structures that protect the soft tissues from underlying bony prominences
- Pain with movement and rest
- Swelling
- PE: Localized tenderness over the site of inflammation when palpated
- If effusion present aspirate fluid to assess for infection vs gout
Excess Iordosis
- flexion deformity of the hip
- As the opposite hip is flexed (with the thigh against the chest), the affected hip does not allow full leg extension
- the affected thigh appears flexed
Hip osteoarthritis
- flexion deformity of the hip
- Restricted abduction
- Restrictions of internal and external rotation
ROM of knee
bend knee
extend knee
- check while ambulating
Bulge sign
- minor effusion
- milk down on marginal side to find fluid
Balloon sign
- major effusion
- feel for extra pressure or fluid
Ballottement of patella
- major effusion
- press on relaxed patella
How to test for a meniscal injury?
McMurray’s test
McMurray’s Test
- With the patient supine, grasp the heel and flex the knee.
- Cup your other hand over the knee joint with fingers and thumb along the medial and lateral joint line.
- From the heel, rotate the lower leg internally and externally.
- Then push on the lateral side to apply a valgus stress on the medial side of the joint.
- At the same time, rotate the leg externally and slowly extend it.
- If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear.
How to test for the ligament laxity or a tear of the medial collateral ligaments?
Valgus stress test
Valgus stress test
- With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table.
- Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle.
- Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress).
- Pain or a gap in the medial joint line points to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries are on the medial side.
How to test for the ligament laxity or a tear of the lateral collateral ligaments?
Varus or adduction stress test
Varus stress test
- Place one hand against the medial surface of the knee and the other around the lateral ankle.
- Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress).
- Pain or a gap in the lateral joint line points to ligamentous laxity and a partial tear of the lateral collateral ligament.
How to test for an ACL tear?
- Anterior drawer test
- Lachman test
Anterior drawer test
- With the patient supine, hips flexed and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings.
- Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur.
- Compare the degree of forward movement with that of the opposite knee.
- A forward jerk showing the contours of the upper tibia is a positive anterior drawer sign, for an ACL tear
- ACL= pull
- PCL = push
Lachman test
- Place the knee at 15 degree flexion and externally rotated
- Grasp the distal femur on the lateral side with one hand and the proximal tibia with the other
- Simultaneously, pull the tibia forward while pushing the femur back.
- Estimate the degree of forward excursion of the tibia
- Forward excursion indicates ACL tear
Posterior Drawer test
- Position the patient and place your hands in the positions described for the anterior drawer test.
- Push the tibia posteriorly and observe the degree of backward movement in the femur.
- Isolated PCL tears are rare, result from a direct blow to the proximal tibia
How to test PCL tear?
Posterior drawer test
ROM of ankle
Ankle/Plantar flexion (point foot to floor)
Ankle extension/ dorsiflexion (point foot to ceiling)
Inversion (bend heel inward)
Eversion (bend heel outward)
Gout
- Very painful and tender, hot, dusky red big toe
- swelling that extends beyond the margin of the joint. Usually on great toe
- easily mistaken for a cellulitis.
- Acute gout may also involve the dorsum of the foot.
- Caused by build up of sodium urate or uric acid which is a by product of purines and dehydration
- can erode bone over time
Pseudo- gout
- Calcium pyrophosphate deposition (CPPD)
- Mono or poly-articular joint pain caused by build of calcium pyrophosphate in the joint
- Inflammation of the joint and periarticular area
- Older population >60 yrs of age
- Difficult to distinguish between gout
- Requires aspiration of synovial fluid for definitive diagnosis
Pes Planus
- flat feet- longitudinal arch is flat and touches floor
- may only be seen when pt. stands
- foot becomes convex, not concave like normal
- may have tenderness on medial malleolus down to medial- plantar surface of the foot
- swelling develops anteriorly to malleoli
- inspect pt. shoes for inner side excess wear
Plantar fasciitis
- Inflammation of a the plantar fascia
- common causes of heel pain.
- Age 40-60 younger in runners
- Risk factors:
Obesity
Prolonged standing or jumping
Flat feet
Reduced ankle dorsiflexion
Heal spurs
Hallux Valgus
- the great toe is abnormally abducted in
- the head of the first metatarsal may enlarge on its medial side, and a bursa may form at the pressure point, which may become inflamed.
Pes Varus
toes point inward
Pes Valgus
toes point outward
Foot corn
- painful, red, conical thickening of skin that results from recurrent pressure on normally thin skin.
- The apex of the corn points inward and causes pain.
- occur over bony prominences such as the 5th toe.
- called soft corns when located in moist areas such as pressure points between the 4th and 5th toes
Callus
- an area of greatly thickened skin that develops in a region of recurrent pressure, like the sole of the foot
- Involves skin that is normally thick, such as the sole
- usually painless
- If a callus is painful, suspect an underlying plantar wart.
Plantar Wart
- Caused by HPV
- Common on the ball of the foot
- Can be tender to touch and painful with ambulation
Osteoarthritis
Degenerative joint disease Breakdown of the cartilage in the joint Age related Non-inflammatory, can be unilateral Affects, knees, hips, hands, spine, wrists Morning stiffness
PE findings of Pt. with osteoarthritis
Heberden’s Nodes of DIP
Bouchard’s Nodes of PIP
Does not affect the MCP
Herberden’s Node
bony swelling of DIP
Bouchard’s Node
bony swelling of PIP
Rheumatoid Arthritis
- Autoimmune disorder with chronic inflammation of the synovial membrane and surrounding tissue
- Symmetric involvement of hands and feet, wrist, ankle, elbows, ankles
- Occurs at any age
- Morning stiffness >1 hour
- Joints tender, warm, red, swollen
- runs in families
- Fatigue
PE findings of pt. with rheumatoid arthritis
Boutonneire Deformity of PIP
Swan neck deformity
Reiter’s Syndrome
- Arthritic disorder causing inflammation of the joints, commonly the spine
- Inflammation of the intestinal, urinary tract, eyes and skin (have red eyes)
- Symptoms do not occur all at once and are not always present with the joint pain
- More common in men
Swan neck deformity
DIP flexes
PIP bends in, looks concave
Polymyalgia Rheumatica
- Chronic self limiting pain with unclear etiology
- Insidious or abrupt onset, can be night time pain
- Usually >50 occurs with giant cell arteritis (temporal arteritis)
- Symmetric Pain around hip, shoulders, neck
- Swelling and edema maybe present over dorsum of hands, wrist and feet
- Muscles tender but not warm or red
- Joint stiffness in am
- Pain will limit movement
- May have associated depression, anorexia, weight loss
Fibromyalgia
- Chronic MS pain disorder affecting the soft tissue
- Felt to be related to aberrant pain signaling that amplifies the pain response
- Pain “all over” neck, shoulders, hands, low back and knees, trigger points on exam
- Pattern can shift, maybe exacerbated by cold, immobility,
- Associated with fatigue, depression/anxiety, headaches, cognitive fogginess
- no changes in joints or muscles
