MSK Exam (Pitcher 10 questions) Flashcards by Andrea Parsons

what 3 bones are in the shoulder girdle

clavicle
scapula
proximal humerus

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what are the 4 articular surfaces of the shoulder

glenohumeral, sternoclavicular, acromioclavicular, scapulothoracic

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what are the 5 main muscles of the shoulder

deltoid - abduct

supraspinatous - abduction

infraspinatous - external rotation

subscapularis - internal rotation

teres minor - external rotation

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intrinsic injury of the shoulder?

glenohumeral ligaments; bone to bone or sprain or tear

muscle or tendon inflammation, tear, strain; rotator cuff or deltoid

bones; fracture, inflamed capsule

common intrinsic pathology:

impingement
tendinopathy
tendon tear
AC separation
osteoarthritis
adhesive capsulitis
bursitis
instability
SLAP lesion

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what are some extrinsic causes of shoulder pain

reproduction of their pain should be none or minimal at best

neuro

cervical nerve root compression
supraspinatous nerve compression
brachial plexus lesions
herpes zoster

abdominal

diaphragm irritation
ruptured ectopic pregnancy

cardio

Myocardial ischemia
thoracic outlet syndrome

thoracic
-pulmonary ebmolus
lung tumor

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if you can reproduce shoulder pain, what is the more likely etiology

more likely an intrinsic injury

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tests for supraspinatous

empty can test

resist elbow coming out

drop arm test

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tests for subscapularis

lift off test

resist elbow coming out medially

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infraspinatous and teres minor tests

pt’ rotates forearms laterally against resistance

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most common cause of tendon or muscle source of pain in the shoulder

supraspinatous

Originates on superior aspect of scapula

Inserts on greater tubercle of humerus

Passes through narrow area between acromion and head of humerus

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how is the supraspinatous injured

repetitive motion

baseball, painters, UPS- pinched in abduction

only protected by subacromial bursa

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when abducting arm the shoulder shrugs upward from the effort of the deltoid in early abduction. There is a positive drop arm test

what does this indicate

complete supraspinatous tear

Weakness of the cuff muscles allow upward migration of the humeral head during use which irritates the supraspinatus tendon and/or muscle from impingement on the acromion. This results in tendinopathy which can lead to a tear.

Acute tears can happen with more forceful injury mechanisms.

Disuse atrophy of supraspinatus or deltoid seen, crepitus or grating noise when lifting arm.

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night pain common
gradual onset
atrophy of superior and posteiror shoulder muscles
localized tendernes is NOT common but pain and crepitus or sudden pain while abducting the arm is common

impingement

-can lead to a rotator cuff tear

Weakness of the rotator cuff can lead to superior subluxation of the humeral head when the shoulder is abducted beyond 90 degrees, predisposing to impingement syndromes. Surgical treatment options often necessary for satisfactory results.

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hawkins sign

sign of impingement

flex the patients shoulder and elbow to 90 deg with the palm facing down

then with one hand on the forearm and one on the arm, rotate the arm internally, by applying upward force at the elbow and downward force on the forearm

this compresses the greater tuberosity against the coracoacromial ligament

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neer’s sign

impingment sign

press on the scapula to prevent scapular motion with one hand ,and raise the pt’s arm with the other. (Like the pt’ is raising their hand to ask question)

this compresses the greater tuberosity of the humerus against the acromion

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what is the cross over test and what is it testing

adduct the arm across the pt’s chest to put strain on the AC join

pain indicates a problem with that joint

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atrophy
significant loss of both passive and active ROM

generally tender with crepitus

loss of joint space

bone spur possible

arthritis of shoulder joint

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what is the initial and best imaging study for arthritis of shoulder

X-ray

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any reason for long standing loss of generalized ROM

muscle atrophy

significant loss of both active and passive ROM

generally tender but MORE complaints of stiffness and creptius

worse pain at night

Adhesive capsilitis

this is inside the capsule and not the true joint

Physical therapy ROM initial treatment. Surgical release/adhesion reduction needed in more severe cases.

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what is a significant risk factor for adhesive capsulitis

Diabetes mellitus

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what is the best imaging for adhesive capsulitis

MRI best to define soft tissue thickening and fibrosis

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how do you tell apart bursitis from tendonitis

Tender, good clue between bursa and tendonitis is pain difference with active vs passive ROM. Can inject then test ROM and strength again to help discern etiology

how do you diagnose bursitis

Ultrasound can help, but diagnosis is primarily by clinical exam and therapeutic challenge (injection)

a lateral versus posterior shoulder joint injection

lateral –> more access to bursa

posterior –> more access to joint

lateral lidocaine injection —> angle of entry parallels the acromion

what is the purpose of the lidocaine injection test

Patients with a rotator cuff tear will have persistent weakness despite pain relief with injection, while those with rotator cuff tendonopathy will have normal strength in association with pain relief. Patients with a frozen shoulder will have persistent loss of range of motion. Dramatic reduction in pain and improvement in overall shoulder function after injection of the subacromial bursa effectively rules out a significant glenohumeral joint process. The lidocaine injection test in the subacromial bursa is indicated when the history and physical examination cannot effectively exclude an underlying rotator cuff tendon tear, a developing frozen shoulder, or concurrent involvement of the acromioclavicular (AC) joint.

common in throwing athletes and those who do lots of work overhead also caused by preventing a fall by grabbing onto something or lifting something heavy suddenly that engages the biceps anterior pain, clicking or reproduction of pain in certain positions, particularly abduction and external rotation.

SLAP lesion Superior Labrum (anterior to posterior) Treatment often conservative for non-professional athletes. Surgical recovery 6-12 months. this lesion occurs where the biceps tendon anchors to the labrum

how do you diagnose a SLAP lesion

MRI

what is X-ray most indicated for

traumatic etiology

how do you test the integrity of the labrum

O'brien's test flex arm to 90 deg. adduct across the chest and internally rotate with the thumb pointing down then push down on the arm. pain is positive test for a labral tear

age >40 pain increases with reaching frequent repetitive activity at or above shoulder pain with apley scratch test (External rotation and abduction) normal PASSIVE ROM normal strength pain with Neer and Hawkins test

rotator cuff tendinopathy rotator cuff tear has all the same findings except there is weakness present and the pt' is middle aged and older

pain increases when carrying objects with elbows bent or lifting overhead

biceps tendinopathy

sudden increase in shoulder pain with popeye deformity pain with resisted elbow flexion or supination

biceps tendon rupture

lateral hip tenderness

bursitis exaggerated or abnormal movement of gluteus medius and TFL over greater trochanter. Gait and all that can affect it key area of investigation. Lateral hip pain. Just posterior superior to point of trochanter. If chronic, the bursa will fibrose and lose it’s ability to provide a more frictionless surface for movement.

lateral pain with paresthesia

meralgia paresthetica

posterior hip pain

SI lumbar unusual true hip joint pathology

anterior/groin pain

true hip joint injury osteonecrosis, sepsis, fracture, synovitis

lower anterior thigh pain

referred true hip injury upper femur injury femoral neck lumbar radiculopathy

what if neither direct pressure nor ROM reproduces pain what are you thinking for diagnosis

hernia lower abdominal pathology referred pain from lumbar area

if you are suspecting a trochanteric bursitis what issues or history do you want to know?

Lumbar muscle tightness Leg length discrepancy Knee or ankle arthritis Varus/valgus stance or gait Do they wear orthotics? Gait asymmetry for any reason. What does the bottom of their shoes look like? Wear pattern even, twisting?

activity pain, occurring at night when more advanced groin, aggravated by movement groin pain, aggravated by movement, more than palpation Key features: restricted abduction!! internal rotation is limited b/c of pain limited flexion and morning stiffness (geling phenomenon) abnormal patrick test

osteoarthritis of the hip

joint destruction (collapse) within 3-5 years groin pain, weight bearing and motion induced most common rest pain and night pain also seen early diagnosis necessary

osteonecrosis one way blood supply of the femoral head also known as aseptic necrosis, avascular necrosis or osteochondritis dissecans. Compromised vascular supply to the femoral head.

what are some etiologic factors associated with osteonecrosis of the femoral head

steroids excessive alcohol intake 90% of cases sickle cell renal failure pregnancy femoral neck fx

severe pain to light weight bearing | intolerable hip rotation ROM

occult fracture

how is the diagnosis of occult fracture made

MRI!! plain film is not sensitive enough stabilize the fx and wait--> re-xray in 7-10 days and now will see white line

when do you suspect that the "Hip pain" is actually referre pain from lumbar and SI Joint

``` Suspect: Whenever groin pain accompanied by back pain Symptoms extend beyond the knee, Paresthesia is present and Direct exam of the hip is unremarkable. ```

what is significant pain at ROM of hip end point a strong indicator of

osteonecrosis occult fx acute synovitis mets

how do you confirm tronchanteric bursitis

local anesthetic block

how do you confirm diagnosis of osteoarthritis of hip

standing AP pelvis X-ray

osgood schlatter what is this? treatment?

osgood schlatter is a disease of overuse caused by repetitive strain and chronic avulsion of the secondary ossification center (apophysis) young age (9-14)- most common in children who have undergone a rapid growth spurt very active in sports Findings: pain and swelling at the tibial tubercle pain relieved by rest pain reproduced by extending the knee against resistance pain control, continue activity, leg strengthening through physical therapy Knobby knee can be permeant

what is best imaging study for osgood schlater

lateral radiograph

what test is most sensitive for osteonecrosis of hip joint

MRI most sensitive

pain, weakness and atrophy in the hips/legs

lumbar radiculopathy CT or MRI is needed to show nerve compression

difference b/w strain and sprain

strain- muscle or tendon sprain - ligaments

if you suspect osteoporotic fracture, what would you ask or look for?

``` fair thin, heavy smoker positive family history minor trauma before onset post-menopausal ```