MSK exam Flashcards
Synovial Joints
what are they
3 types and associated movements
Synovial Joints
- freely moveable; articular cartilage lines each boney promince & contain a synovidal cavity
- knee, shoulders
Types of Synovial Joints
Spheroidal (ball & socket joints)
- convex & concave in shape
- allow for a wide range of motion: felx,extend, ab/add, rotate and circumduction (3 degrees of freedom)
- these rely on fibrocartialge on the bones for support
- examples: shoulder and hip
Hinge
- flat, planar motion & shape
- motion occurs within one plane, flexion and extension
- examples: elbow, joints of the hand/foot
Condylar/Condyloid
- convex and concave in shape
- movement of two articulating surfaces: not dissociable
- move with flex/extend and add/abd
- example: wrist
Cartilagnous Joint
2 kinds
Cartilagnous Joints
- slightly moveable
- examples: vertebral bodies, pubic symphysis & sternomanubrial joint
Fiberocartilaginous Discs
- separate bony surfaces
- compressible
- abosrb shock well: like the nucleus pulpous in vertebrae
Hylaine (Articular) Cartilage
- cover the surfaces of bone on either side of a joint
- help to decrease friction & distribute load/weight properly
Fiberous Joint
Fibrous
- immovable
- skull sutures
Spinal Anatomy
33 vertebrae
- protect, support and remain flexible
- contain IV discs & allow for proper ROM (extension, flexion, rotation & side to side bending
- primary curvature: kyphotic (thoracic and sacral) ( when baby: curve over)
- secondary curvature: lordotic (happens with movement)
Cervical Spine
- small, extensive articuar surface
- increased ROM (increased risk of injury)
Thoracic Spine
- rigid, long spinous process & demifacets
- limited mobility
Lumbar Spine
- strong and weight-bearing
- flexibility returns at L3(weight distribution through)
Bursae
other intra-articualr strucutres
Bursae
- disc-shaped synovial sacs between muslces and articualr surfaces: prevent friction
- faciliate motion
- decrease friction
- elbows and knees and shoulders
Other Intra-articular structures
- joint capsule
- articaulr cartialge
- synvoium
- synovial fluid
- intra-articualr ligments
- periarticualr ligaments (LIgament = Bone to Bone)
- tendons (Muscle to bone)
Joint Pain: history taking
monoarticular, oligo and poly
- point with 1 finger to pain
- establish MOA of trauma
- determine if arthralgia (joint) v myalgia (muscle)
if the pain is….
Monoarticuar
- one joint invovled
- trauma
- monoarticualr OA
- bursitis
oligoarticualr
- 2-4 joints
- infection or septic arthritis
- connective tissue issue
- OA
Polyarticualr
- 4+ joints
- suggests viral or inflammatory RA SLE or psoriasis
questions to ask
- symmertical, intermittent, migrate?
Rhumatic fever/gonococcal arthriis = migrate from one joint to other
RA: additive, starts at one then adds another symmetrically
psoriatic arthriis, reactive or IBD = asymmertric
acute = days/months
chronic - months to years
inflammatory joint issues (RA) = worse with rest, activity is better
mehanical issue (OA) = worse with activity, better with rest
inflammatory pain will be worse than mechanical pain
Features of Inflammation in the joints
calor= heat
dolor = pain
rubor = redness
tumor = swelling
ask about constitutional = fever/chills
high fever = septic arthritis
lowe fever = RA/crystal-induce arthritis
other inflammation = bursitis, tendonitis, tenosynovitis, sprains
Decreased ROM : things to ask
Stiffness: percived or resisted motion
temporal pattern of decreased ROM
- worse in teh AM (RA)
- intermittent (OA)
change to ADLS
ask about PROM and AROM in articular pain and periarticualr pain
how to approach the MSK exam
IPPA = IPROMS inspect, palpate ROM then special tests
- look at posturing when they walk in
Inspection
- look at joints for deformities and malalignment
- crepitus
- inflammation
- compare bilaterally
ROM
- active (the pt. does it)
- passive (you do it)
TMJ
- some snapping is common WNL
- can do a strength test of the muscles too
Spine
- ROM
Spurlings Test : cervical nerve root impingment
Straight Leg Test
- tests for lumbar radiculopathy L4-S2
- a Positive sign is between 35-70 degrees of hyperextension of the hip pain is felt posteriorly = nerve impingment
Waddell Sign
- a test for patients who were likely to experience a poor outcome with psychogenci factors of low back pain
- 5 categories: tenderness, simulation, distraction, reginal, overreation
- + sign = psychological alert that the paitnet may warrent a complete psych eval.
Mechanial V radicular v systemic pain in the spine
Mechanial = axial pain
- caused by facet joing degeneration and micro/macro instability
- worse with activity and lifting/prolonged standing
Musculogenic: muscle pain
- stiffness
- pain with bending
Neurogenic/radicualr pain
- unilateral pain
- dermatomal pain
neurogenic claudication
- spinal stenosis
- pain worse with standing in the legs and butt
systemic pain
- constitutional symptoms
- think of systemic illnesses
The Shoulder
bones, joints, muscles
ROM tests
three bones
- humerus, clavicle and scapula
three joints
- AC
- sternoclav.
- glenohumeral
Subacromial bursa
- abduction = compression of this bursa
SITS muscles
- supraspinatus
- infraspinatus
- subscap
- teres minor
ROM Tests
Cross Body Adduction Test
- AC joint pathology
- passive adducting the arm
- + = pain at AC joint
Hawkins Impigment Sign
- tests for rotator cuff disorder or adhesive capsulitis
- felx elbow to 90 degrees, palm down and internally rotate
Shoulder ROM test
Apley Scratch Test
Assessment of the compound movements of the shoulder, ROM of GH joint and assess RTC tears
- pt. reaches behind head and touches opposite scapular and other hand from underneath
- + = uncoordinated movement or ROM defict when they switch sides
Scapular Winging Test
Pt. pushes against a wall : look at medial scapula boarder for winging
Painful Arc Test
tests for subacromial impingement syndrome
pt: abducts arm up to 180 degrees
- + test = pain between 60-120 degrees
- pain should go awaya once past 120
Neers Test
tests for subacromial impingment syndrome
- stabilze the pt. scapula and have them flex arm in internal rotation (bring up to raise hand)
- = pain
External and Internal Lag Test
External
test for supra/infraspinatus tears or subacromial impingment
- flex arm to 90, bring outwards and hold there
- + = dropped arm
Internal (“Lift Off”)
- Tests for subscapular pathology
- hand to small of their back, lift off and hold
- + = unable to hold it there
Drop Arm Test
Empty Can Test
tests for supraspinatus and biceps tendinitis
- ask them to abduct arm to shoulder level and lower slowly
- = unable to slowly lower = will just drop the arm
Empty Can Test
- test supraspinatus tear
- -arms out front, thumbs to floor; put pressue as pt. resists
- + = weakness
External Rotation Resistnace Test
test infraspinatus pathology
- pt arms to their sides at 90 degrees, thumbs up & you push from inside to out & have them resist the external rotation
- = weakness
Rotato Cuff Tendinitis (Impigment Syndrome)
- repettive shoulder motions like throwing/swiming which overtime impinge and inflame the tendon
- pt. complain of = catches of pain, weakness of lifting arm
- see pain at the tip of acromion
- neers test
- painful arc
Rotator Cuff Tear
chronic impingement or trauma
- can be full or partial thickness tear
- commonly supraspinatus tear
PT. Complains
- chronic pain
- nighttime pain
- weakness
- pseudo-paralysis (if traumatic)
PE
- extreme pain and weakness
- + drop arm test
- atrophy crepitus
Biceps Tendonitis
- inflammation of the biceps tendon (long head) and the tendon sheath
- can be associated with rotator cuff tendinitis
- can be the result of long standing impingment injuries
Compliants of
- anterior shoulder pain
- pointing to the bicipital groove
PE
- preserved ROM
- TTP at the grooce
- + Yeargasons test (pain with resisted supanation)
- + speed test (forward flexion)
Adhesive Capsilitis
- fiberosis of the glemnohumeral joint
compliants of
- diffuse, dull and achy pain
PE
- substiantail asymmetry in the AROM and PROM and deficts of the ROM
- usually a unilateral issues: 40-60 year olds & needs th “thaw”
Acromioclavicular Arthritis
- degenerative changes to the articualr surfaces of the AC joint
Complanints of
- focal pain at AC joint
- history of trauma
- overhad athlete
PE
- pain with palpation at AC joint
- + cross body & with abduction
Shoulder Dislocation
Anterior: more common due to fall, overhead athletes
Posterior: tonic-clonic seizure, electrical shock, etc.
Complaints of
- trauma
- nocturnal dislocation
PE
- limited ROM
- visable defrmity
- + sulcus sign
- + apprehension
reduce immediately!!
half of posteriore are missed: be on the look out
The Elbow
bones joints and landmarks
nerves
Bones
- humerus
- radius
- ulna
joints
- radiohumeral joint
- humeroulnar
- radioulnar
Landmarks
- medial epicondyle
- lateral epicondyle
- olecranon bursa
nerves
- ulnar
- radial
- median
Cozen Test
testing for lateral epicondlytis tennis elbow
- stablize: ask them to pronate and extend wrist against resistances
- = reproducable pain along the lateral epicondyle
Tinels Sign (elbow)
testing for ulnar nerve irritation
at the ELBOW
- tap in the groove between the olecranon process, medial epicondyle
+ = tingling along the ulnar distrubtuion (pinkey and 1/2 ring finger)
Olecranon Bursitis
- secondary to trauma, gour or RA
complaints of
- elbow pain
PE
- large, tense, and sometimes red bursa
- aspirate for symptom relief
Lateral Epicondylitis
tennis elbow
- repetitive extension of the wrist or propation/supanation of forearm chronic tendinosis of the ECRB
Compliants
- pain with activity at the lateral epicondylitits
PE
- pain with resisted wrist extension
- pain 1 cm distal to the lateral epicondlye
Medial Epicondylitis
pithcers elbow, golfers elbow wtc.
repetitive flexion tendonosis of the PT (pronator teres) or FCR (flexor carpi radialis)
Complinats
- pain with activity at medial epicondyle
PE
- pain with resisted wrist flexion
Wrist and Hands
bones joints
carpel tunnel
soft tissue structure
Bones
distal radius
ulna
carpal bones
metacarpals
P, M and D phalanges
Joints
- radiocarpals
- intercarpal joints
Soft Tissue
- six extensor tendons
- 2 flexor tendons
Carpel Tunnel
- sheath and flexor tendons fot the thumb and fingers
- Median nerve runs here
Hand Grip Strength
- testing weakness in fingers = flexors
- ask pt. to grasp your seconda dn thirs fingers
- sign = weakness in grip
Tinel Test (hand)
Phalen
finkelstein test
Tinel Test
- tap for carpal tunnel in median nerve alignment
- + = tingling at median distrubution
Phalen
- test carpel tunnel
- - make 90 degree angle and hold them together
- tingling = + test
Finkelsteins test
- tests for de quervains tenosynovitis
- thumb to palm and move wrist midline
- + = pain
Osteoarthritis (OA)
progressive joint weardown
Complains
- pain & stiffness
Heberden nodes : at the DIP : a hard boney overgrowth, painless/hard nodes
+ = flexion and deviation deformities
Bouchards nodes : at the PIP : less common
MCP spared in OA
Acute Rheumatoid Arthritis
Complaints of
- tender, painfull and stiff symmetric invovlement of joints
PE
- PIP and MCP commonly involved
- can have rhumatoid nodules
- fusiform or spindle-shaped swelling of the PIP can be seen
Chronic Rheumatoid Arthritis
a chronic disease = thickening of the MCP and PIP
- decreased ROM with ulnar deviation
PE findings
Swan neck deformities : hyperextension of the PIP with fixed flexion of the DIP
boutonnieres deformity : persistant flexion of teh PIP and hyperextension of the DIP
Dupuytrens Contracture
- a benign fibrosing disorder of the palmar fascia & unknown cause
- higher incidence in alcoholics and chronic systemic disorder
Complaints
- “whats wrong”
PE
- a nodule or cord-like thickening of the 4th or 5th digit
- puckering of the skin
- limited finger extension with preserved flexion
Trigger Finger
- painless nodule in the flexor tendon in the palm & near the metacarpal head
- the nodules exceed the size of the tendon sheath
on PE
- affected finger will be flexed position
- audible and palpale snap as finger extends and flex as the nodule pops into the sheath
Ganglion Cyst
- a cystic round and usually nontender that swells along the tendon sheath or joint capsule
- cyst = synovial fluid built up
PE
- usually on the dosum of the hand or wrist and prominent with flexion
Hip Joint
bones invovled
stability
muscule groups for ROM
bursa
nerves
strong, stable joint with ROM
- ball and socket joint: deep acetabulum & confluence of all three pelvic bones coming together
stable due to
- dee fit of acetabulum
- strong fiberous capsule
- powerful muscles
Relevent Muscles
- Flexor group: anterior, illiopsoas
- extensor group: posteroir, gluteus max
- adductor : pull inwards, adductor longus
- abductor : pull lateral, glutuen med and min
Bursa
- psoas buras
- ischial bursa
- trochanteric bursa
nerves
- sciatic nerve
Hip movement: Gait
60% of normal gait is stance and 40% is swing of foot
Patrick Test (FABER)
test for hip, lumbar, SI pathology and illopsoas spasm
flexion, abduction, external rotation
figure four of leg as pt. is laying down
a + test = pain with resisted adduction and the knee remains above the opposite leg
Kendall Test
Tests for hip flexion deformity and rectus femoris contracture
pt is seated, thighs half way off table, ask them to lay flat and flex one leg to the chest while otehr elg remains at 90 degress over edge of table
+ test = lift off and leg extension of the leg at 90 degrees
Knee
Bones
comparments
valgum/varum
Bones
- femur (has condyles)
- tibia (flat)
- patella
Compartments
- medial femorotibial
- lateral femorotibial
- patellofemoral
Bursa throughout
bakers cyst (popliteal fossa)
there is no staibility to the joint itself, only the ligaments which hold it in place are stable
VALGUM: knees inward: a lateral force pushing inwards “gummy knees together”
VARUS: knees outward: bow leg: medial pushing laterally “rum makes your legs open”
Bulge Sign (minor effusions)
milk edema dowwards inot joint space
apply medial pressure & tap from lateral back to medial to feel fluid wave
+ = test for effusion if felt a medial buldge
Patellar Ballottement (Major effusions)
- squeeze leg superior to knee to force fluid downward
- push patella sharply against the femur
- feel for a palpable tap or rebound of the patella striking against your fingertips = + positive signs
the patella is rebounding off the fluid behind it
Balloon Sign (major effusion)
- thumba nd index finger on each side of the patella
- left hand compresses the pouch on the femur
- palpate for fluid ejected into the spaces in either side of teh patella = + test
MCl and LCL tests
MCL = Valgus stress test
- push from lateral to medial (start with 30 degrees away from body then push inwards)
LCL = Varus stress test
- push from medial to lateral
+ test = no firm endpoint
ACL and PCL tests
anterior drawer: ACL
posterior drawer: PCL
+ test = no firm endpoint
Lachmans Test
tests for the ACL
- knee at 15 degrees of flexion: mild external rotation
- 1 hand on femur laterally
- 1 hand on tibia medially
- simultaneously push and pull (push femur in and tibia out)
+ test = no firm endpoint
McMurrys Test
Meniscus test
- place the hand over the knee, rotate leg internal or external (depending on medial or lateral test) and then apply pressure towards whcihever menisuc your testing and extend and flex the knee
a positive test = pain, popping or clicking at the joint line
Foot and Ankle
Bones and Joints
- tibia
- fibula
- talus (only ankle bone to articulate with the above)
mortise (tibiotalar joiint)
subtalar (talocalcaneal)
medial and alteral malleoli
calcaneusand metatarsals
gout = first MTP
hallux valgus = bunions
hammer toe = 2nd toe curls
Thompson Test
achilles tendon rupture
pt. lays, squeeze calf , shold plantarflex
no plantar flexion = postive test for rupture
Hallux Valgus (bunions)
lateral deviation of teh great toe and enlargemetn of teh head of the first metatarsal
Compliants of
- inflammed bursae and pain
- more common in women
PE
- lateral deviation of the toe and redness
GOuty Attack
acute gout attack = inflammation at the first MTP joint
Complaints of
- acute onset of severe pain and trouble walking
PE
- focal redness atht e base of the 1st MTP and can be mistaken for cellulitis
Mortons Neuroma
- perineural fibrosis of the common digital nerve due to repeititve irritation
complaints of
- tenderness over the plantar surface betweeen 3rd and 4th metatarsals
- parasthesias
PE
- pain with pressing on the plantar interspaces
- pain worse in teh AM
Pes Planus
Pes Cavus
Pes Planus
- loss of the longitudinal arch due to posterior tibial tendon dysfunction
- pain = along the medial side of teh foot and medial malleolus
- can be apparent when standing (flat foot)
Pes Cavus
- elevation of the plantar arch
- frequently due to underlying neurological disorders
- complain of heel or cuboid pain
- high arched foot
