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PCM IV Exam I > MSK Exam (Pitcher 10 questions) > Flashcards

MSK Exam (Pitcher 10 questions) Flashcards

1
Q

what 3 bones are in the shoulder girdle

A

clavicle
scapula
proximal humerus

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2
Q

what are the 4 articular surfaces of the shoulder

A

glenohumeral, sternoclavicular, acromioclavicular, scapulothoracic

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3
Q

what are the 5 main muscles of the shoulder

A

deltoid - abduct

supraspinatous - abduction

infraspinatous - external rotation

subscapularis - internal rotation

teres minor - external rotation

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4
Q

intrinsic injury of the shoulder?

A

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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5
Q

what are some extrinsic causes of shoulder pain

A

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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6
Q

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

A

more likely an intrinsic injury

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7
Q

tests for supraspinatous

A

empty can test

resist elbow coming out

drop arm test

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8
Q

tests for subscapularis

A

lift off test

resist elbow coming out medially

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9
Q

infraspinatous and teres minor tests

A

pt’ rotates forearms laterally against resistance

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10
Q

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

A

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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11
Q

how is the supraspinatous injured

A

repetitive motion

baseball, painters, UPS- pinched in abduction

only protected by subacromial bursa

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12
Q

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

A

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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13
Q

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

A

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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14
Q

hawkins sign

A

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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15
Q

neer’s sign

A

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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16
Q

what is the cross over test and what is it testing

A

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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17
Q

atrophy
significant loss of both passive and active ROM

generally tender with crepitus

loss of joint space

bone spur possible

A

arthritis of shoulder joint

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18
Q

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

A

X-ray

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19
Q

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

A

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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20
Q

what is a significant risk factor for adhesive capsulitis

A

Diabetes mellitus

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21
Q

what is the best imaging for adhesive capsulitis

A

MRI best to define soft tissue thickening and fibrosis

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22
Q

how do you tell apart bursitis from tendonitis

A

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

23
Q

how do you diagnose bursitis

A

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

24
Q

a lateral versus posterior shoulder joint injection

A

lateral –> more access to bursa

posterior –> more access to joint

lateral lidocaine injection —> angle of entry parallels the acromion

25
Q

what is the purpose of the lidocaine injection test

A

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.

26
Q

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.

A

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

27
Q

how do you diagnose a SLAP lesion

A

MRI

28
Q

what is X-ray most indicated for

A

traumatic etiology

29
Q

how do you test the integrity of the labrum

A

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

30
Q

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

A

rotator cuff tendinopathy

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

31
Q

pain increases when carrying objects with elbows bent or lifting overhead

A

biceps tendinopathy

32
Q

sudden increase in shoulder pain with popeye deformity

pain with resisted elbow flexion or supination

A

biceps tendon rupture

33
Q

lateral hip tenderness

A

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.

34
Q

lateral pain with paresthesia

A

meralgia paresthetica

35
Q

posterior hip pain

A

SI
lumbar
unusual true hip joint pathology

36
Q

anterior/groin pain

A

true hip joint injury

osteonecrosis, sepsis, fracture, synovitis

37
Q

lower anterior thigh pain

A

referred true hip injury

upper femur injury

femoral neck

lumbar radiculopathy

38
Q

what if neither direct pressure nor ROM reproduces pain

what are you thinking for diagnosis

A

hernia

lower abdominal pathology

referred pain from lumbar area

39
Q

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

A

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?

40
Q

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

A

osteoarthritis of the hip

41
Q

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

A

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.

42
Q

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

A

steroids
excessive alcohol intake
90% of cases

sickle cell
renal failure
pregnancy
femoral neck fx

43
Q

severe pain to light weight bearing

intolerable hip rotation ROM

A

occult fracture

44
Q

how is the diagnosis of occult fracture made

A

MRI!!
plain film is not sensitive enough

stabilize the fx and wait–> re-xray in 7-10 days and now will see white line

45
Q

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

A 
Suspect:
Whenever groin pain accompanied by back pain
Symptoms extend beyond the knee, 
Paresthesia is present and 
Direct exam of the hip is unremarkable.
46
Q

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

A

osteonecrosis
occult fx
acute synovitis
mets

47
Q

how do you confirm tronchanteric bursitis

A

local anesthetic block

48
Q

how do you confirm diagnosis of osteoarthritis of hip

A

standing AP pelvis X-ray

49
Q

osgood schlatter

what is this?
treatment?

A

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

50
Q

what is best imaging study for osgood schlater

A

lateral radiograph

51
Q

what test is most sensitive for osteonecrosis of hip joint

A

MRI most sensitive

52
Q

pain, weakness and atrophy in the hips/legs

A

lumbar radiculopathy

CT or MRI is needed to show nerve compression

53
Q

difference b/w strain and sprain

A

strain- muscle or tendon

sprain - ligaments

54
Q

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

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

PCM IV Exam I (5 decks)

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