MUSCULOSKELETAL Flashcards
Red Flags for Low Back Pain from Underlying Systemic Disease
● Age <20 years or >50 years
● History of cancer
● Unexplained weight loss, fever, or decline in general health
● Pain lasting more than 1 month or not responding to treatment
● Pain at night or present at rest
● History of intravenous drug use, addiction, or immunosuppression
● Presence of active infection or human immunodeficiency virus (HIV) infection
● Long-term steroid therapy
● Saddle anesthesia, bladder or bowel incontinence
● Neurologic symptoms or progressive neurologic deficit
the most abundant mineral in the body, is essential for bone health, muscle function, nerve transmission, vascular function, and intracellular signaling and hormonal secretion
Calcium
Recommended Dietary Intakes of Calcium and Vitamin D for Adults
19-50 years old
51-70 yrs old
Women
Men
71 and older
Age Group Calcium mg/d Vitamin D IU/d
19–50 yrs 1,000 600
51–70 yrs
Women 1,200 600
Men 1,000 600
71 & older 1,200 800
Once injured, articular cartilage is replaced by less resilient ____, increasing risk of pain and OA.
fibrocartilage
Risk factors for falls include
- increasing age,
- impaired gait and balance,
- postural hypotension,
- loss of strength,
- medication use,
- comorbid illness,
- depression,
- cognitive impairment,
- visual deficits.
There are two phases to range of motion:
active (by the patient) and passive (by the examiner)
malalignment of bones or joints occurs in
Dupuytren contracture, bow-legs (genu varum) or knock-knees (genu valgum)
Four Signs of Inflammation
- Swelling
- Warmth
- Redness
- pain or tenderness
Palpable bogginess or doughiness of the synovial membrane indicates ___, which is often accompanied by effusion.
synovitis
Palpable joint fluid is present in effusion, tenderness over the tendon sheaths in
tendinitis
The principal muscles opening the mouth are the
external pterygoids
is a fibrocartilaginous ring that surrounds the glenoid and deepens its socket,
providing greater stability to the humeral head.
labrum
In this joint, the head of the humerus articulates with the shallow glenoid fossa of the scapula. This joint is deeply situated and normally not palpable. It is a ball-and-socket joint, allowing the arm its wide arc of movement—flexion, extension, abduction (movement away from the trunk), adduction (movement toward the trunk), rotation, and circumduction.
glenohumeral joint
The convex medial end of the clavicle articulates with the concave hollow in the upper sternum.
sternoclavicular joint.
The lateral end of the clavicle articulates with the acromion process of the scapula.
acromioclavicular joint.
Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear within 2 to 3 weeks of a
rotator cuff tear
Beginning medially, at the ____, trace the clavicle laterally with your fingers.
sternoclavicular joint
From behind, follow the bony spine of the scapula laterally and upward until it becomes the ___, the summit of the shoulder. Its upper surface is rough and slightly convex.
acromion
With your index finger on top of the acromion, just behind its tip, press medially with your thumb to find the slightly elevated ridge that marks the distal end of the clavicle at the acromioclavicular joint. Move your thumb medially and down a short step to the next bony prominence, the ____of the scapula.
coracoid process
With your thumb on the coracoid process, allow your fingers to fall on and grasp the lateral aspect of the humerus to palpate the ___, where the SITS muscles insert.
greater tubercle
Next, to palpate the ____ in the intertubercular bicipital groove, keep your thumb on the coracoid process and your fingers on the lateral aspect of the humerus. Remove your index finger and place it halfway between the coracoid process and the greater tubercle on the anterior surface of the arm. As you check for tendon tenderness, rolling the tendon under the fingertips may be helpful. You can also rotate the glenohumeral joint externally, locate the muscle distally near the elbow, and track the muscle and its tendon proximally into the intertubercular groove.
biceps tendon
To examine the subacromial and subdeltoid bursae and the SITS muscles, first
passively extend the humerus by lifting the elbow posteriorly, which rotates these structures so that they are anterior to the acromion. Palpate carefully over the subacromial and subdeltoid bursae. The underlying palpable SITS muscles are:
■ Supraspinatus—directly under the acromion
■ Infraspinatus—posterior to supraspinatus
■ Teres minor—posterior and inferior to the supraspinatus
■ Subscapularis—inserts anteriorly and is not palpable
The six motions of the shoulder girdle are
- flexion,
- extension,
- abduction,
- adduction, and
- internal and external rotation.
to test pure glenohumeral motion, the patient should raise the arms to shoulder level at __, with palms facing down.
90°
To test scapulo-thoracic motion, the patient should turn the palms up and raise the arms an additional ____.
60°
An age of ≥60 years and a positive __ are the findings most likely to identify a degenerative rotator cuff tear
drop-arm test
are the most common cause of shoulder pain in primary care.
Rotator cuff disorders
Five maneuvers that have the best LRs and the narrowest confidence intervals are currently recommended:
- one pain provocation test,
- three strength tests, and
- one composite test.
This test has a positive LR of 3.7, which is the highest of all the rotator cuff maneuvers. It also has the best negative LR, 0.36, for ruling out rotator cuff disorders
Pain provocation test: painful arc test (subacromial bursa and rotator cuff)
These tests have positive LRs of 7.2, 5.6, and 3.3, respectively.
Strength tests:
- internal rotation lag test (subscapularis),
- external rotation lag test (supraspinatus and infraspinatus), and
- drop arm test (supraspinatus).
This test has a positive LR of 2.6. Another common composite test is the empty can
test.
Composite test: external rotation resistance test (infraspinatus).
Pain with adduction is a positive test doing crossover or crossed body adduction test, with a positive LR of
3.7
Acromioclavicular joint tenderness and compression tenderness have ___ LRs so are not diagnostically helpful.
low
Structure that uses Crossover or crossed body adduction test. Adduct the patient’s arm across the chest.
Acromioclavicular Joint
Structure that uses Apley scratch test. Ask the patient to touch the opposite scapula using Tests abduction and external rotation. Tests adduction and internal rotation.
Overall Shoulder Rotation
Painful arc test. Fully adduct the patient’s arm from 0° to 180°.
Rotator Cuff Pain Provocation Tests
Shoulder pain from 60° to 120° is a positive test for a subacromial impingement/rotator cuff ____, with a positive LR 3.7 and a helpful negative LR of 0.36.
tendinitis disorder
Press on the scapula to prevent scapular motion with one hand, and raise the patient’s arm with the other.
This compresses the greater tuberosity of the humerus against the acromion.
Neer impingement sign
Flex the patient’sshoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament.
Hawkins impingement sign
With the patient’s arm flexed to 90° with palm up, rotate the arm into full external rotation.
External rotation lag test.
Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°. Then you lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position.
Internal rotation lag test.
Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle.
Drop-arm test.
Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pressure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation.
External rotation resistance test.
Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask
the patient to resist as you place downward pressure on the arms.
Empty can test
Pain during Apley scratch test suggests a
rotator cuff disorder or adhesive capsulitis
Pain during Neer impingement sign is a positive test for a subacromial impingement/rotator cuff tendinitis disorder, with a positive LR ~ ___.
1.0 to 1.6
Pain during Hawkins impingement sign is a positive test for supraspinatus impingement/rotator cuff tendinitis, with a positive LR of ∼___. When both the Hawkins and Neer signs are absent, the negative LR is helpful at 0.1.
1.5
Inability of the patient to maintain external rotation is a positive test for supraspinatus and infraspinatus disorders, with a positive LR of ___.
7.2
Inability of the patient to hold the hand in this Internal rotation long test is positive test for a subscapularis disorder, with a positive LR of ____ and an excellent negative LR of 0.04.
5.6 to 6.2
Weakness during Drop-arm test is a positive test for a supraspinatus rotator cuff tear or bicipital tendinitis, with a positive LR of ___.
3.3
Pain or weakness during Externnal rotation resistance test is a positive test for an infraspinatus disorder, with a positive LR of and negative LR of 0.49. Limited external rotation points to glenohumeral disease or adhesive capsulitis.
2.6
Inability of the patient to hold the arm fully abducted at shoulder level or control lowering the arm is a positive test for a suprasinatus rotator cuff tear (Empty can test), with a positive LR of
1.3
