MSK Flashcards
Characteristics/quality of pain: Nerve Bone Vascular Muscle
Nerve: sharp, burning, follows a nerve
Bone: deep, localized
Vascular: diffuse, aching, poorly localized, many be referreed
Muscle: dull and aching, poorly localized, may be referred
Referred sites of pain: Neck Back Appendix Heart/diaphragm
Neck: arm
Back: leg
Appendix: (hip) right iliac fossa
Heart/diaphragm: shoulder
Inflammatory versus degenerative pain characteristics
Inflammatory: morning stiffness > 30 min, pain w/ erythema, warmth, swelling, responds to NSAIDS
Degenerative: pain worse at end of day, after activity, morning stiffness < 30 min if present
Neurologic symptoms
cauda equina symptoms, bowel/bladder incontinence or retention, headaches, weakness
Claudication: vascular symptoms
Exercise-induced, no pain at rest, pain stops within 10 min of stopping activity. Calf, buttocks, thigh, foot pain. Must differentiated from neurogenic symptoms (spinal stenosis, sciatica)
SEADS
Swelling Erythema Atrohpy Deformity Skin changes
WETCJ
Warmth Effusion Tenderness Crepitus Joint stability
Causes of hypermobile joints
Ligament
Collegen disorders
Tendinitis
RA
Causes of hypomobile joints
muscle strains
pinched nerves
tendinitis
OA
What is end-feel? What are the different types?
End-feel is felt by the examiners hand at the end of passive ROM.
Bone - bone: cold stop, elbow extension
Soft tissue approximation: muscles coming together like pillows squishing, elbow flexion
Tissue stretch: springy/firm with slight give, tendons stretching, wrist flexion
ADLS (DEATH)
dressing eating ambulating toileting hygiene
Trendelenburg sign
contralateral hip drop (lift good leg)
Trendelenburg gait
waddle
Circumduction gait
leg swings around
Limp
Antalgic
Impingement syndrome (shoulder) characteristics
night pain
dull ache
weakness with arm drop test
atrophy of rotator muscles
Rotator cuff injury
Weakness with arm drop
Atrophy of rotator cuff muscles
Night pain
Subacromial bursitis
Tenderness at anterior-inferior acromion
Limited ACTIVE ROM but full PASSIVE ROM
Bicipital tendon rupture (Proximal)
Asymmetry with bulge deformity
Sharp ache
Hx trauma
Bicipital tendonitis
Overuse injury
Dull ache
Tenderness over biceps groove
Labral tear
Hx trauma (dislocation) or overuse (throwing injury).
Mimics rotator cuff!!
Instability.
Suspect based on demographic, hx, lack of response to conservative treatment.
AC pathology
Painful Arc
Painful and tender over AC
Adhesive capsulitis
Frozen shoulder.
Early phase pain may be the only symptom.
Pain at night or with movements to constant pain.
Later phase global restriction in active or passive ROM
Consider fasting glucose - prevalent in DM.
Axillary nerve mononeuropathy
shoulder flexion/abduction/external rotation (FEAR) weakness. Atrophy deltoid teres minor.
Suprascapular nerve palsy
overhead abduction, external rotation weakness (OAR)
Long thoracic nerve injury
Shoulder flexion and overhead. Scapular winging and atrophy of serrates anterior.
Rotator cuff tear
unable to raise arm overhead, positive arm drop test/empty can test
Cervical nerve root lesion
myotome weakness. Pain and sensation reduction in dermatome distribution, Reduced DTR.
Spinal accessory nerve pathology
Traps, SCM, scapular winging. Reduced flexion and abduction.
SITS
supraspinatus
infraspinatus
teres minor
subscapularis
Shoulder ROM
Forward flexion 180 Backward flexion 60 Abduction 180 Adduction 50 ER 90 IR 70
Shoulder assessment:
Inspection and Palpation
Inspection: contours, clavicles, SC/AC joints, scapulae, SEADS
Palpation: SC/AC/GH joints. Biceps groove, subdeltoid bursa, AC joint and rotator cuff insertion. Check GH for crepitus by palpation of subacromial bursa and passive circumduction
Special tests for: General shoulder instability
o Anterior apprehension: push forwards (anteriorly) on humeral head while externally rotating shoulder passively. Popping or fear of pain/dislocation = positive.
o Relocation test: posterior pressure on humeral head = resolved apprehension (positive)
o Anterior release test: positive if when releasing hand (from postrior pressure above) = pain/apprehension
o Load and shift: compress into glenoid (stabilize) and stabilize scapula then move humeral head anterior/posterior… shift should be < 25% ant and < 50% posterior
o Sulcus: pull arm vertically down (anatomic position), if humeral head slides inferiorly or gap = positive
Special tests for: Glenoid labral pathology
o O’Brien’s: adduct and internally rotate arm, then apply downward pressure against resistance… then repeat w/ externally rotate. Postive = pain with supination, relief with pronation.
o Anterior slide: hands on hips, stabilize clavicle and scapula, push up and forwards on elbow
Special tests for: Rotator cuff tears:
o Drop arm test
o Empty can test: arms 45 degrees, thumbs down, push up against force
o External rotation resistance
o Internal rotation lag: arms behind back, 90 degrees, examiner lifts hand off back. Positive test = patient cannot hold.
o Gerber lift-off test – same set up as internal rotation but patient lifts their hand off back against resistance, pain or cannot lift.
Special tests for: Impingement syndrome:
o Neer’s test: stabalize scapula. Internally rotate and forward flex arm. Anterolateral shoulder pain = positive test.
o Hawkins-Kennedy test – with shoulder and elbow flexed at 90 degrees, passively internally rotate shoulder. Pain = supraspinatus impingement.
o Painful arc test: posive test pain at 60-120 degrees abduction
Special tests for: AC joint pathology
o Scarf test (across body adduction test): adduct on horizontal plane. Positive test: pain in AC
Special tests for: Bicipital tendonitis:
o Yergason test: patient attempt to supinate arm and flex elbow against resistance. Pain = biceps tendonitis
o Speed’s test: patient flexes shoulder to 60 degrees, elbow extended, arm supinated. Resists downward pressure. Positive = pain in bicipital groove.
Shoulder dislocation: anterior vs posterior
Anterior: slight abduction & IR (Anterior = AIR)
Posterior: sulcus adduction and ER
AC joint pathology characteristics
swelling, bruising, prominent clavicle
AC joint separation common in sports
Poor ROM and moderate pain when raising arm
SCARF test
Rare complication = brachial plexus injury => assess neurovasc
Elbow assessment: Inspection and Palpation
Inspection: swelling, masses, note carrying angles,, symmetry, flexion contractures, hyperextension
Palpate:
Cubital fossa contents: biceps tendon, brachial artery, median nerve
Muscles: biceps, pronator teres, flexor carpi radialis and ulnaris, palmaris longus, flexor digitorum superficialis
Medial and lateral epicondyles, medial and lateral collateral ligaments, ulnar head and radial head
olecranon, olecranon bursa, triceps
Elbow ROM
Flexion 180
Extension 0
Supination 80-90
Pronation 80-90
Special tests for radial or cubital tunnel syndrome
Tinel test (tap the ulnar nerve, or the ‘funny bone’… between olecranon process and medial epicondyle)
Special tests for medial epicondylitis
1) Active resisted D3 flexion
2) Palpate medial epicondyle and passively supinate and extend elbow then extend wrist. Pain at medial epicondyle = positive
Special test for lateral epicondylitis
Extend elbow and wrist in pronation. Have patient actively resist {extension against resistance) while trying to flex the wrist
• Positive test = pain with lateral epicondyle
????
Olecranon bursitis
Minor trauma. Focal swelling at posterior elbow. Aseptic (gradual); septic (sudden).
Ulnar nerve subluxation
Medial elbow pain, snapping sensation, ulnar distribution parenthesis
Wrist ROM
flexion 80 extension 70 radial deviation 20 ulnar deviation 30 supination 80-90 pronation 80-90
Carpal tunnel
night-time median nerve distribution tinel and phalen Katz hand diagram pertinent negative: normal thumb abduction strength
De Quervain’s
weakness of grip and pain at base of thumb
Finkelstein test! flex thumb and close fingers over it, then move into ulnar deviation… pain = positive
Extensor carpi ulnaris tendinopathy:
- Ulnar/radial deviation = snapping
- Can tear the ECU subsheath, causing instability/subluxing of the tendon
- Press thumbs together pain on ulnar side
Ganglion cyst:
- Dorsal or volar hand mass, maybe be painful
* Palpable, firm, transilluminates, vascular exam to exclude arterial impingement
TFCC (triangular fibrocartilage complex) injury:
- Pain with turning doorknob. MOI fall on extended/pronated wrist.
- Soft spot volar to styloid process
Keinbock’s disease:
- lunate bone AVN
- Progressive dorsal wrist pain with activity, hx wrist trauma
- Decreased ROM, grip. Effusion. Tender radiocarpal joint.
Ulnocarpal abutment syndrome
dorsal/ulnar sided wrist pain, worse with ulnar deviation and grip
FOOSH injuries (3)
Distal radius (Colle’s): pain, fork-like deformity
Distal radioulnar joint subluxation (DRUJ): Snapping/crepitus, pronation with compression of the ulna against the radius, decreased grip strength
Scaphoid:
snuffbox pain/tenderness/swelling
Can result in AVN –> painful radoiocarpal & CMC ROM. Hx trauma with or without fracture
What motor responses do the radial, median and ulnar nerves control?
Radial: finger extension, thumb and wrist
Median Thumb IP flexion, index/finger flexion, wrist flexion
Ulnar: finger ab/adduction
Long flexor tendon avulsion
pain after eccentric forced DIP flexion
Finger rests at slight extension compared to other digits
unable to actively flex DIP, tender solar distal finger
What are some differentials for spine pain?
- Degenerative (90%)
- Spinal stenosis (claudication-like pain… caused by osteophyte, central disc, congenital… neural involvement of a particular root)
- Peripheral nerve compression (radiculopathy from disc herniation)
- Infection
- Cauda equina
- Fracture
- Spondyloarthropathies
- Referred pain (aorta, renal ureter, pancreas).
Radiculopathy (spine)
L4/L5 or S1S2
pain worse with back movement, constant pain (at some point)
Neck ROM
flexion 90
Extension 70
side flexion 20-45
rotation 70-90
Cervical spine myotomes
Neck flexion C1-C2 Neck side flexion C3 Shoulder elevation C4 Shoulder abduction C5 Elbow flexion and/or wrist extension C5/C6 Elbow Extension and/or wrist flexion C7 Thumb extension and/or ulnar deviation C8 Abduction and/or adduction of hands T1
upper extremity reflexes
Biceps C5, C6
Triceps C6, C7, C8
Brachioradialis C5, C6
Wainner’s criteria for cervical radiculopathy
3/4 of the following:
- cervical rotation < 60
- Spurling’s test (side flex neck toward affected side, positive test is reproduction of radicular symptoms)
- distraction test (pull on head = relief of symptoms)
- upper limb tension sign: reproduction of symptoms = positive test)
What does Adam’s forward bend test demonstrate?
scoliosis if prominent rib
Thoracic outlet syndrome
- Thoracic outlet ring is formed by top three ribs, just below collarbone.
- TOS occurs when nerves or blood vessels are compressed by ribs.
- Arterial, venous, neurogenic
- Often caused by a cervical rib – which compresses subclavian artery
- Ischemia one hand (bilateral reynold’s)
- Palpate radial pulse while applying traction to arm. Obliteration of pulse positive test
- Paresthesia is usually severe
- May have hypothenar wasting.
lower extremity reflexes
Patellar L3, L4
Medial hamstring L5, S1
Achilles S1, S2
Ectomorphic
Mesomorphic
Endomorphic
Ectomorphic – little body fat
Mesomorphic – heavily muscles – little body fat
Endomorphic – large amt body fat
what might café au lait spots indicate?
neurofibromatosis
lower extremity myotomes
Hip flexion L2 Knee extension L3 Ankle dorsiflexion L4 Great Toe Extension L5 Ankle Plantar Flexion, Ankle Eversion, Hip Extension S1
Tests for lumbar disc herniation
- Straight leg test
- Ankle dorsiflexion against resistance is more precise than heel stand test
- Calf wasting
- Can also measure: femoral stretch test (prone – hip extension = pain = L2-L4), rib to pelvis distance (normal is 3 fingerbreadths)
Cervical spondylosis:
cervical pain and suboccipital headache. Cervical radiculopathy – sensory dysfunction and/or motor dysfunction.
Whiplash symptoms:
suboccipital HA. Progressive onset of neck pain (peak 12-72 hrs post-trauma)
Ankylosing spondylitis
insidious onset, back pain > 3 months, patients < 40. Pain worse in AM, improves with exercise and NSAIDS.
spinal stenosis
back pain walking or standing, relieved with sitting or flexed position, focal weakness o sensory changes.
Hip ROM
Hip ROM Flexion 120 Extension 30 Abduction 45 Adduction 30 Rotation (Flexion/Extension, Internl/External) 45
FADIR
flexed, adducted, internally rotated… anterior impingement syndrome
FABER (Figure 4)
Hip, SI joint, iliopsoas spasms
Ober’s
Pt side lying… Passively move leg to hook the IT band over greater trochanter and their leg remains elevated…
snapping hip (iliopsoas bursitis)
audible snap/clunk at inguinal crease when extending hip from flexed position… can be painful
Piriformis syndrome
leg and buttock pain with radiation to lower extremity consistent with sciatic nerve impingement. Decreased internal rotation.
Special knee tests or fluid/effusion:
o Patellar: displace suprapatellar pouch by sliding hand down then press on patella, click = positive
o Ballotment: ballot the fluid between medial and lateral patellar fossa
o Bulge test: move fluid from medial to lateral, back to medial. Positive if small effusion, negative if large
Special knee tests for ligament pathologies:
o Anterior drawer (mvt > 1.5cm = ACL tear)
o Lachman: push femur/pull tibia. 84% sensitive for ACL
o Posterior drawer: PCL tear (mvt > 1 cm)
o Posterior Sag sign:
o MCL
o LCL
Special knee tests for menisci:
o McMurray: flex knee, externally rotate foot, and extend knee, if click or pain = positive
o Lateral meniscus: same as McMurray but internally rotate foot
patellofemoral syndrome (runner’s knee)
anterior pain, dull ache, worse when going down stairs.
Patellar tendinopathy (jumper’s knee)
overuse… anterior pain with jumping localized to patellar tendon
Foot ROM
Plantar flexion 50 Dorsiflexion 20 Inversion of heel 35 Eversion of heel 15 Supination of forefoot 35 Pronation of forefoot 15
plantar fasciitis
gradual onset, posteromedial heel pain with chronic overuse, worst when getting out of bed and at the end of day
Lisfranc fracture (tarsometatarsal fracture/dislocation)
hyperplantarflexed forefoot
Morton’s neuroma
pain 2nd and 3rd metatarsal heads, web space paresthesia, worse with tight shoes
Bunion
hallux valgus deformity
Charcot foot
foot and ankle swelling, may be painless. Deformity (rocker bottom), sensory deficit
6 P’s of compartment syndrome
- Pain
- Pallor
- Paresthesia
- Paralysis
- Pulselessness
- Poikilothermia
