Musculoskeletal Flashcards
Danger Signals
N_____ Fracture (Sc____ Bone Fracture)
C____ Fracture
Acute Osteo____
H__ Fracture
P____ Fracture
C____ E____ Syndrome
Low-back Pain (From A Dissecting (1))
Bone M______
Navicular Fracture (Scaphoid Bone Fracture)
Colles Fracture
Acute Osteomyelitis
Hip Fracture
Pelvic Fracture
Cauda Equina Syndrome
Low-back Pain (From A Dissecting Abdominal Aneurysm)
Bone Metastases
Navicular Fracture (Scaphoid Bone Fracture)
Wrist pain on palpation of the (1) Pain on axial loading of the ____.
History of _____ forward with _____ hand (hyperextension of the wrist) to break the fall.
Initial x-ray of the wrist may be normal, but a repeat x-ray in 2 weeks will show the _____ fracture (due to callus bone formation).
High risk of avascular ____ and non_____.
_____ wrist (thumb spica splint) and refer to a hand ______.
Wrist pain on palpation of the anatomic snuffbox Pain on axial loading of the thumb.
History of falling forward with outstretched hand (hyperextension of the wrist) to break the fall.
Initial x-ray of the wrist may be normal, but a repeat x-ray in 2 weeks will show the scaphoid fracture (due to callus bone formation).
High risk of avascular necrosis and nonunion.
Splint wrist (thumb spica splint) and refer to a hand surgeon.
Colles Fracture
Fracture of the distal _____ (with or without ulnar fracture) of the forearm along with dorsal displacement of wrist.
History of _____ forward with _____ hand (as in navicular fracture).
This fracture is also known as the “(1)” fracture because of the appearance of arm and wrist after the fracture.
It is the ____ common type of wrist fracture.
Fracture of the distal radius (with or without ulnar fracture) of the forearm along with dorsal displacement of wrist.
History of falling forward with outstretched hand (as in navicular fracture).
This fracture is also known as the “dinner fork” fracture because of the appearance of arm and wrist after the fracture.
It is the most common type of wrist fracture.
Acute Osteomyelitis
=
Most common bacterial cause =
Patient complains of l______ bone pain, swelling, redness, and tenderness of affected area and f_____. If on leg or hip, may refuse to w___ and bear weight.
An acute infection of the bone that causes inflammation and destruction, which can be caused by bacteria, mycobacteria, and fungi.
Most common bacteria that causes osteomyelitis is Staphylococcus aureus.
Patient complains of localized bone pain, swelling, redness, and tenderness of affected area and fever. If on leg or hip, may refuse to walk and bear weight.
Acute Osteomyelitis
Most cases are due to contiguous spread from a nearby infected _____ to the bone. For example, an infected p______ sore on the heel can cause osteomyelitis of the heel bone, or calcaneus (non_______ spread).
Hematogenous spread is seeding of the bone from an infection in the bloodstream (_____emia). For example, a patient with bacteremia complains of refractory vertebral pain and tenderness (hematogenous osteomyelitis).
Direct tr_____ to the bone can also result in infection.
Most cases are due to contiguous spread from a nearby infected wound to the bone. For example, an infected pressure sore on the heel can cause osteomyelitis of the heel bone, or calcaneus (nonhematogenous spread).
Hematogenous spread is seeding of the bone from an infection in the bloodstream (bacteremia). For example, a patient with bacteremia complains of refractory vertebral pain and tenderness (hematogenous osteomyelitis).
Direct trauma to the bone can also result in infection.
Acute Osteomyelitis Workup and Treatment
Imaging of choice?
Labs?
Treatment?
MRI can show changes to the bone and bone marrow before plain x-ray or radiograph.
White blood cell (WBC) count, erythrocyte sedimentation rate (ESR; sed rate), and C-reactive protein (CRP) are elevated. Blood cultures may be positive.
Antibiotic treatment is based on culture and sensitivity (C&S) results. May need surgical debridement, amputation, and bone grafts.
Hip Fracture
Patient has a history of slipping or f____. Sudden onset of ___-sided hip pain. Unable to ____and bear weight on affected hip.
If mild fracture, may bear weight on affected hip. If displaced fracture, presence of severe hip pain with _____ rotation of the hip/leg (abduction) and leg _____.
More common in ____. Elderly have a 1-year mortality rate from 12% to 37% related to complications of immobility, such as pn____ and deep vein _______.
Patient has a history of slipping or falling. Sudden onset of one-sided hip pain. Unable to walk and bear weight on affected hip.
If mild fracture, may bear weight on affected hip. If displaced fracture, presence of severe hip pain with external rotation of the hip/leg (abduction) and leg shortening.
More common in elderly. Elderly have a 1-year mortality rate from 12% to 37% related to complications of immobility, such as pneumonia and deep vein thrombophlebitis.
Pelvic Fracture
History of significant or high-energy trauma such as a (1) or (1) accident.
Signs and symptoms depend on degree of injury to the pelvic bones and other pelvic structures such as n____, blood vessels, and pelvic organs.
Look for ecc_____ and swelling in the lower ab____, hi__, gr____, and/or scr____. May have bladder and/or fecal in_____, vaginal or rectal bl____, ____turia, ____ness. May cause internal h______, which can be life-threatening.
Check (1)’s first!
History of significant or high-energy trauma such as a motor vehicle or motorcycle accident.
Signs and symptoms depend on degree of injury to the pelvic bones and other pelvic structures such as nerves, blood vessels, and pelvic organs.
Look for ecchymosis and swelling in the lower abdomen, hips, groin, and/or scrotum. May have bladder and/or fecal incontinence, vaginal or rectal bleeding, hematuria, numbness. May cause internal hemorrhage, which can be life-threatening. Check airway, breathing, and circulation first (the ABCs).
(1)
Acute onset of saddle anesthesia, bladder incontinence (or retention of urine), and fecal incontinence. Accompanied by bilateral leg numbness and weakness. Pressure (most common cause is a bulging disc) on a sacral nerve root results in inflammatory and ischemic changes to the nerves.
A surgical ____. Needs spinal de______. Refer to ___.
Cauda Equina Syndrome
Acute onset of saddle anesthesia, bladder incontinence (or retention of urine), and fecal incontinence. Accompanied by bilateral leg numbness and weakness. Pressure (most common cause is a bulging disc) on a sacral nerve root results in inflammatory and ischemic changes to the nerves.
A surgical emergency. Needs spinal decompression. Refer to ED.
(1)
Acute and sudden onset of “tearing,” severe low-back/abdominal pain. Presence of abdominal bruit with abdominal pulsation. Patient has signs and symptoms of shock. More common in elderly males, atherosclerosis, White race, and smokers.
Low-back Pain (From A Dissecting Abdominal Aneurysm)
Bone Metastases Symptoms
Bone pain can feel achy, sharp, and well l_____, or it can feel like _____pathic pain (burning shooting pain).
It can be severe with n____ pain and/or pain with ____bearing.
It may be accompanied by night ____, malaise, f____, and weight ____.
It can be constant or intermittent and can get exacerbated with m_____of the joint or bone.
Bone pain can feel achy, sharp, and well localized, or it can feel like neuropathic pain (burning shooting pain).
It can be severe with night pain and/or pain with weight bearing.
It may be accompanied by night sweats, malaise, fever, and weight loss.
It can be constant or intermittent and can get exacerbated with movement of the joint or bone.
Bone Metastases
Bone is one of the most common sites of distant metastases. Pathologic _____ may occur.
Routine labs may show elevated levels of alkaline _____ and/or serum (1) electrolyte.
Cancers of the pr_____, br___, l___, th____, and k____ make up the majority (80%) of cases of bone metastases.
Most sensitive and specific imaging test (1)*?
Bone is one of the most common sites of distant metastases. Pathologic fractures may occur.
Routine labs may show elevated levels of alkaline phosphatase and/or serum calcium (hypercalcemia).
Cancers of the prostate, breast, lung, thyroid, and kidney make up the majority (80%) of cases of bone metastases.
In general, MRI* is the most sensitive and specific imaging test.A radiograph (x-ray) has poor sensitivity (44%–50%), but it can show bony lesions and may show early lesions.
Joint Anatomy
(1): Thick serous clear fluid (sterile) that provides lubrication for the joint
- ____ synovial fluid can be indicative of infection; order C&S
(1): Space between two bones (the joint) filled with synovial fluid
(1): The cartilage lining the open surfaces of bones in a joint
(1): Crescent-shaped cartilage located in each knee; two in each knee
- Damage to menisci may cause l_____ of the knees and knee in______.
Synovial fluid: Thick serous clear fluid (sterile) that provides lubrication for the joint
- Cloudy synovial fluid can be indicative of infection; order C&S
Synovial space: Space between two bones (the joint) filled with synovial fluid
Articular cartilage: The cartilage lining the open surfaces of bones in a joint
Meniscus or menisci (plural): Crescent-shaped cartilage located in each knee; two menisci in each knee
- Damage to menisci may cause locking of the knees and knee instability.
Joint Anatomy
(1): Connects muscle to the bone (partial or complete tear of tendon or muscle is a strain)
(1): Connects bone to bone (partial or complete tear of a this is a sprain)
(1): Saclike structures located on the anterior and posterior areas of a joint that act as padding; filled with synovial fluid when inflamed (1)
- _____ fluid is abnormal and is indicative of infection.
Tendon: Connects muscle to the bone (partial or complete tear of tendon or muscle is a strain)
Ligament: Connects bone to bone (partial or complete tear of a ligament is a sprain)
Bursae: Saclike structures located on the anterior and posterior areas of a joint that act as padding; filled with synovial fluid when inflamed (bursitis)
- Cloudy fluid is abnormal and is indicative of infection.
Benign Variants
- Genu recurvatum:*
- Genu valgum:*
- Genu varum:*
- Genu recurvatum:* Hyperextension or backward curvature of the knees
- Genu valgum:* Knock-knees
- Genu varum:* Bowlegs
Exam Tip
To remember valgum, think of “___ stuck between the ____” (knock-knees). The opposite is varus, or ___ legs.
To remember valgum, think of “gum stuck between the knees” (knock-knees). The opposite is varus, or bowlegs.
Exercise and Injuries
Within the first __ hours, protect joint, and acutely inflamed joints should not:
- Be _____ in any form (not even isometric exercises)
- Engage in any active (1) exercises; if done too early, they will cause more inflammation and damage to the affected joints
Undergo exacerbating activities
Within the first 48 hours, protect joint, and acutely inflamed joints should not:
- Be exercised in any form (not even isometric exercises)
- Engage in any active range-of-motion (ROM) exercises; if done too early, they will cause more inflammation and damage to the affected joints
Undergo exacerbating activities
RICE Mneumonic
Within the first 48 hours after musculoskeletal trauma, follow these rules:
Rest**: Avoid using injured joint or limb.
Ice**: Apply cold packs on injured area (e.g., 20 minutes on, 10 minutes off) for first 24 to 48 hours.
Compression: Use an elastic bandage wrap over joints to decrease swelling and provide support. Joints that are usually compressed are the ankles and knees.
Elevation**: This prevents or decreases swelling. Avoid bearing weight on affected joint.
Recommendation for Exercise in Adults
How much aerobic exercise?
How much muscle strengthening?
Aerobic exercise is good to bring down what vital sign in adults?
150 to 300 minutes weekly of moderate-intensity aerobic activity (or 75 to 150 minutes of vigorous aerobic activity) +
Muscle strengthening exercise at least 2 days a week.
In hypertensive adults, aerobic exercise has been found to lower resting clinic systolic/diastolic BP
Recommendation for Exercise in Children to Teens
How much aerobic exercise?
How much muscle strengthening?
60 minutes daily of moderate-to-vigorous physical activity +
Muscle-strengthening and bone strengthening activity 3 times per week
Non-weight-bearing exercise
Isometric exercise definition
Example of an isometric exercise?
Is biking and swimming non weight bearing exercises?
Isometric exercises are non-weight-bearing exercises that are performed in a fixed state in which the muscle is flexed against a stationary object.
An example is pushing one fist against the palm of the other hand, which is stationary.
Biking and swimming are aerobic exercises, which are non-weight-bearing (do not strengthen bones).
Weight-bearing exercise
In weight-bearing exercises, the bones/muscles are forced against ____.
Weight-bearing exercise is recommended for treating (1) to help strengthen bone dur_____.
Examples include?
In weight-bearing exercises, the bones/muscles are forced against gravity.
Weight-bearing exercise is recommended for treating osteoporosis/osteopenia to help strengthen bone durability.
Examples include walking, yoga, tai chi, skiing, weight lifting, other sports
Drawer Sign
Tests for what?
Excessive laxity is suggestive of a?
Drawer sign is a test for knee stability.
Excessive laxity of affected knee is suggestive of a torn ligament.
Anterior Drawer Sign
How to perform maneuver?
What is a positive exam?
Patient lies on examination table (supine). The hip is flexed to 45 degrees, and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to stabilize the knee joint. Then examiner grasps the lower leg by the joint line and pulls the tibia anteriorly (like opening a drawer).
A positive anterior drawer sign is indicative of a damaged or torn anterior cruciate ligament (ACL).
Posterior Drawer Sign
How to perform maneuver?
What is a positive test?
Patient lies on examination table (supine). The hip is flexed to 45 degrees, and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to stabilize the knee joint. Then examiner grasps the lower leg by the joint line and pushes it posteriorly (like closing a drawer)
A positive posterior drawer sign is indicative of a damaged or torn posterior cruciate ligament (PCL). Sensitivity is 90%, and specificity is 99%.
Finkelstein’s Test
Tests for what condition?
How to perform the test?
What is a positive test?
De Quervain’s tenosynovitis (or tendinosis) is caused by an inflammation of the tendon sheath, which is located at the base of the thumb
Tell patient to flex thumb toward the palm, then make a fist by folding remaining fingers over the thumb, then tell patient to ulnarly deviate their wrist.
Positive if there is pain and tenderness on the wrist on the thumb side (abductor pollicis longus and extensor pollicis brevis tendons).
McMurray’s Test
Tests for what condition?
How to perform test?
What is a positive test?
Gold standard test for joint damage is?
Meniscus Injury or Tear
Patient supine and relaxed. The examiner grasps the patient’s heel with one hand and the joint line of the knee with the other hand. The knee is flexed maximally, with external tibial rotation (medial meniscus) or internal tibial rotation (lateral meniscus).
Knee pain and a “click” sound upon manipulation of the knee are positive
Gold-standard test for joint damage is the MRI.
Lachman’s Sign
What does this test for?
How to perform test?
What is a positive sign?
This test vs. anterior drawer sign?
Tests for ACL damage
This test is done by bending the hip 45 degrees and the knee 90 degrees, then pulling the knee forward with a sudden jerk to test the leg’s range of motion.
If it moves 6 mm beyond its normal range of motion, then you may have an ACL tear or injury
Lachman’s test is more sensitive than is the anterior drawer sign
Collateral Ligaments (Knees)
Positive finding is an increase in laxity of the damaged knee (ligament tear).
- Valgus stress test of the knee:* Test for the _____ collateral ligament
- Varus stress test of the knee:* Test for the ____ collateral ligament
Positive finding is an increase in _____ of the damaged knee (ligament tear).
- Valgus stress test of the knee:* Test for the medial collateral ligament (MCL)
- Varus stress test of the knee:* Test for the lateral collateral ligament (LCL)
Joint Injections
Administering intra-articular/periarticular joint injections with _____ (e.g., triamcinolone) is a ______ treatment for inflamed joints.
Some expert panels suggest about ____ injections per joint (such as a knee) in a lifetime.
If high re______ is felt when pushing syringe, do not force. Withdraw needle slightly (do not remove from joint) and re_____.
Administering intra-articular/periarticular joint injections with steroids (e.g., triamcinolone) is a controversial treatment for inflamed joints.
Some expert panels suggest about four injections per joint (such as a knee) in a lifetime.
If high resistance is felt when pushing syringe, do not force. Withdraw needle slightly (do not remove from joint) and redirect.
Joint Injections Complications
- T_____ rupture
- N___ damage
- in____
- bl_____
- (1) axis suppression, others.
Joint injections are contraindicated in patients who are on anti______ therapy because of the risk of hem_____
- Tendon rupture
- nerve damage
- infection
- bleeding
- hypothalamic–pituitary–adrenal (HPA) suppression, others.
Joint injections are contraindicated in patients who are on anticoagulation therapy because of the risk of hemarthrosis (bleeding into joint)
Plain X-Rays (Radiographs)
Show bone _____, osteo_____ (OA; joint space n_____, osteop_____ formation), damaged bone (osteom____, met_____), met___ and other dense objects.
____ recommended for soft tissue structures such as menisci, tendons, and ligaments. Usually the _____ imaging modality
Show bone fractures, osteoarthritis (OA; joint space narrowing, osteophyte formation), damaged bone (osteomyelitis, metastases), metal and other dense objects.
Not recommended for soft tissue structures such as menisci, tendons, and ligaments. Usually the initial imaging modality
MRI
Gold standard for =
MRI uses a magnetic field and radio waves, not ______ (compared with x-rays and CT scans).
Can be done without or with contrast.
Gold standard for injuries of the cartilage, menisci, tendons, ligaments, or any joint of the body.
MRI uses a magnetic field and radio waves, not radiation (compared with x-rays and CT scans).
Can be done without or with contrast.
MRI Contraindications
M_____ implants, ____makers, aneurysm cl____, insulin p____, metallic foreign body in the ____, “trigger____” contact lens, cochlear implant, el_____for deep brain stimulation, and metallic joints.
Metal implants, pacemakers, aneurysm clips, insulin pumps, metallic foreign body in the eye, “triggerfish” contact lens, cochlear implant, electrodes for deep brain stimulation, and metallic joints.
CT
Combines x-rays (_____ radiation) that are rotating in a continuous circle around the patient with computer software to show slices of ____-dimensional images.
Can be done without or with contrast.
Detects bl____, an______, m____, pelvic and bone trauma, fr_____.
Combines x-rays (gamma radiation) that are rotating in a continuous circle around the patient with computer software to show slices of three-dimensional images.
Can be done without or with contrast.
Detects bleeding, aneurysms, masses, pelvic and bone trauma, fractures.
Clinical Pearls
(1): Best for soft tissue, joints, occult fractures, and soft tissue.
(1): Best for bone injuries such as fractures. Some bone fractures might not be visible (e.g., stress fractures).
MRI: Best for soft tissue, joints, occult fractures, and soft tissue.
X-rays (radiographs): Best for bone injuries such as fractures. Some bone fractures might not be visible (e.g., stress fractures).
Orthopedic Terminology
(1): Movement going away from the body
(1): Movement going toward the body
(1): Body part located closer to the body (compared with distal)
(1): Body part farther away from the center of the body
Abduction (varus): Movement going away from the body
Adduction (valgum): Movement going toward the body
Proximal: Body part located closer to the body (compared with distal)
Distal: Body part farther away from the center of the body
Hand Anatomy
- (1):* Bones of the hands.
- (1)*: Bones of the wrist. There are a total of eight wrist bones.
- (1)*: Fingers and the toes; singular form of the term is (1)
- (1):* Bones of the feet.
- (1):* The ankle bone.
- (1):* The heel bone.
- Metacarpals:* Bones of the hands.
- Carpals*: Bones of the wrist. There are a total of eight wrist bones.
- Phalanges:* Fingers and the toes; singular form of the term is phalanx.
- Metatarsals:* Bones of the feet.
- Talus:* The ankle bone.
- Calcaneus:* The heel bone.
Hand Anatomy Picture
Foot Anatomy Picture
(1)
Lower extremity injury caused by overuse, resulting in microtears and inflammation of the muscles, tendons, and bone tissue of the tibia. Also known as “shin splints.”
Medial Tibia Stress Syndrome (Shin Splints) and Medial Tibial Stress Fracture
Medial Tibia Stress Syndrome (Shin Splints) and Medial Tibial Stress Fracture
More common in _______ (higher incidence in females) and people with ____feet. If severe, it can progress into a stress f______.
(1) gender are at higher risk of stress fracture, especially those with “female athlete triad” (3).
Onset precipitated or worsened with intensification of activity (increased mil____ and/or fr_____ of training).
More common in runners (higher incidence in females) and people with flat feet. If severe, it can progress into a stress fracture.
Females are at higher risk of stress fracture, especially those with “female athlete triad” (amenorrhea, eating disorder, osteoporosis).
Onset precipitated or worsened with intensification of activity (increased mileage and/or frequency of training).
Shin Splints Classic Case
(1) gender r_____ reports that she recently increased frequency/distance running and complains of recent onset of pain on the ____ edge of the ____.
Pain may be sharp and stabbing or dull and throbbing. Aggravated during and after exercise. Complains of a sore spot on the inside of the lower leg or the shin (tibia). Some patients may have pain on the ____rior aspect of the shin. Focal area is tender when t_____. Some may develop a stress _____ on the tibia.
Female runner reports that she recently increased frequency/distance running and complains of recent onset of pain on the inner edge of the tibia.
Pain may be sharp and stabbing or dull and throbbing. Aggravated during and after exercise. Complains of a sore spot on the inside of the lower leg or the shin (tibia). Some patients may have pain on the anterior aspect of the shin. Focal area is tender when touched. Some may develop a stress fracture on the tibia.
Shin Splints Non-Pharm Treatment
(1) Mneumonic for several ______ are recommended
Apply ____ packs during acute exacerbation, for ___minutes at a time, several times a day for first 24 to 48 hours and then as needed.
________ bandage or sleeve may help decrease swelling. Using c_______ shoes (sneakers) for daily activity helps decrease tibial stress.
When pain is gone, wait about ___ weeks before resuming exercise. Avoid h____ and very hard surfaces until the shin splints have resolved.
If aerobic exercise is desired, recommend ______ impact exercises (e.g., swimming, stationary bike, elliptical trainer). If stress fracture is suspected, advise patient to _____ exercising.
St____ before exercise and start at _____ intensity. Wear sup_____ sneakers.
RICE for several weeks are recommended
Apply cold packs during acute exacerbation, for 20 minutes at a time, several times a day for first 24 to 48 hours and then as needed.
Compression bandage or sleeve may help decrease swelling. Using cushioned shoes (sneakers) for daily activity helps decrease tibial stress.
When pain is gone, wait about 2 weeks before resuming exercise. Avoid hills and very hard surfaces until the shin splints have resolved.
If aerobic exercise is desired, recommend lower impact exercises (e.g., swimming, stationary bike, elliptical trainer). If stress fracture is suspected, advise patient to avoid exercising.
Stretch before exercise and start at lower intensity. Wear supportive sneakers.
Shin Splints Treatment Plan
Rx(1) as needed for pain
Imaging of Choice if suspecting stress fracture
If fracture is confirmed, refer to _____
NSAIDs as needed
If suspect stress fracture, bone scan and/or MRI. A radiograph (x-ray) does not show stress fractures.
Refer to orthopedic specialist.
(1)
Acute or recurrent pain on the bottom of the feet that is aggravated by walking. Caused by _____ in this area of the foot due to tightness of the Achilles tendon.
Higher risk with ____ (body mass index [BMI] >30), d_____, _____exercise, f____feet, prolonged st______.
Plantar Fasciitis
Acute or recurrent pain on the bottom of the feet that is aggravated by walking. Caused by microtears in the plantar fascia due to tightness of the Achilles tendon.
Higher risk with obesity (body mass index [BMI] >30), diabetes, aerobic exercise, flat feet, prolonged standing.
Classic Case of Plantar Fasciitis
_____-aged adult complains of pl_____ foot pain (either on one or on both feet) that is worsened by w_____ and weight bearing. Complains that foot pain is worse during the first few steps in the m______ and continues to worsen with pro______ walking.
Middle-aged adult complains of plantar foot pain (either on one or on both feet) that is worsened by walking and weight bearing. Complains that foot pain is worse during the first few steps in the morning and continues to worsen with prolonged walking.
Plantar Fasciitis Pharm Tx
- (1):* Naproxen (Aleve) orally twice a day, ibuprofen (Advil) orally every 4 to 6 hours.
- (1):* Diclofenac gel (Voltaren Gel) applied to soles of feet twice a day.
Consider (1) to rule out fracture, heel spurs, complicated case
Refer to (1) as needed
- NSAIDs:* Naproxen (Aleve) orally twice a day, ibuprofen (Advil) orally every 4 to 6 hours.
- Topical NSAID:* Diclofenac gel (Voltaren Gel) applied to soles of feet twice a day.
Consider x-ray to rule out fracture, heel spurs, complicated case
Refer to podiatrist as needed
Plantar Fasciitis Non-Pharm Treatment
Use _____ foot appliance at night for a few weeks; it will help to ____ the _____ tendon.
Stretching and massaging of the foot: ____ a golf ball with sole of foot several times a day.
Lose _____ (if overweight).
Use shoes with well-p_____ soles and/or use a heel ____ on affected foot.
Use orthotic foot appliance at night for a few weeks; it will help to stretch the Achilles tendon.
Stretching and massaging of the foot: Roll a golf ball with sole of foot several times a day.
Lose weight (if overweight).
Use shoes with well-padded soles and/or use a heel cup on affected foot.
(1)
Inflammation of the digital nerve of the foot between the third and fourth metatarsals. Increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners.
Morton’s Neuroma
Classic Case of Morton’s Neuroma
Middle-aged woman complains of many weeks of _____ foot pain that is worsened by walking, especially while wearing high heels or tight narrow shoes. The pain is described as b____ and/or ______ness, and it is located on the space between the ____ and ____ toes (metatarsals) on the forefoot. Physical exam of the foot may reveal a small n_____ on the space between the third and fourth toes. Some patients palpate the same nodule and report it as “peb___-like.”
Middle-aged woman complains of many weeks of plantar foot pain that is worsened by walking, especially while wearing high heels or tight narrow shoes. The pain is described as burning and/or numbness, and it is located on the space between the third and fourth toes (metatarsals) on the forefoot. Physical exam of the foot may reveal a small nodule on the space between the third and fourth toes. Some patients palpate the same nodule and report it as “pebble-like.”
Mulder Test
Test for Morton’s Neuroma
=
What indicates a positive test?
This test for Morton’s neuroma is done by grasping the first and fifth metatarsals and squeezing the forefoot
Positive test is hearing a click along with a patient report of pain during compression. Pain is relieved when the compression is stopped.
Morton’s Neuroma Treatment
Avoid wearing t____ n____ shoes and high _____. Use forefoot p____. Wear well-padded shoes.
Diagnosed by _____ presentation and history. Refer to ______.
Avoid wearing tight narrow shoes and high heels. Use forefoot pad. Wear well-padded shoes.
Diagnosed by clinical presentation and history. Refer to podiatrist.
(1)
Occurs when the cartilage covering the articular surface of joints becomes damaged from overuse and with age. Large weight-bearing joints (hips and knees) and the hands (_____ and ______ nodes) are most commonly affected. It can affect one side or bilaterally. Risk factors include ____ age, _____ of joints, and positive _____ history.
Degenerative Joint Disease (Osteoarthritis)
Occurs when the cartilage covering the articular surface of joints becomes damaged from overuse and with age. Large weight-bearing joints (hips and knees) and the hands (Bouchard’s and Heberden’s nodes) are most commonly affected. It can affect one side or bilaterally. Risk factors include older age, overuse of joints, and positive family history.
Degenerative Joint Disease (Osteoarthritis) Classic Case
Gr____ onset (over years). Early-_____ joint stiffness with inactivity. Shorter duration of joint stiffness () compared with rheumatoid arthritis (RA). Pain aggravated by over____ of joint. During exacerbations, involved joint may be swollen and tender to palpation. May be one-sided (e.g., right hip only). Absence of ______ symptoms (not a systemic inflammatory illness like RA). (2) nodes may be noted
Gradual onset (over years). Early-morning joint stiffness with inactivity. Shorter duration of joint stiffness (<15 minutes) compared with rheumatoid arthritis (RA). Pain aggravated by overuse of joint. During exacerbations, involved joint may be swollen and tender to palpation. May be one-sided (e.g., right hip only). Absence of systemic symptoms (not a systemic inflammatory illness like RA). Heberden’s and/or Bouchard’s nodes may be noted
OA findings
- _______ nodes:* Bony nodules on the distal interphalangeal (DIP) joints
- _______ nodes:* Bony nodules on the proximal interphalangeal (PIP) joints
- Heberden’s nodes:* Bony nodules on the distal interphalangeal (DIP) joints
- Bouchard’s nodes:* Bony nodules on the proximal interphalangeal (PIP) joints
DegenerativeJoint Disease (OA) Goal of Treatment
Relieve ______
Preserve joint m______ and f_______
Minimize dis______ and pr_____ joint.
Relieve pain.
Preserve joint mobility and function.
Minimize disability and protect joint.
Degenerative Joint Disease (OA) Non-Pharm Management
______ (with care) at least three times a week. Lose _____. Stop sm_____.
Do _____ exercises to strengthen ______ muscles (knee OA).
Engage in ____-bearing exercise (walking, lifting weights), ______-band exercises.
Avoid agg______ activities. Use ____ or ____ packs and ultra____ treatment.
Use walking ____. Patellar t_____ by physical therapist will reduce load on knees.
Alternative medicine: Use glucosamine supplements, SAM-e, tai ___exercises, ac______.
Exercise (with care) at least three times a week. Lose weight. Stop smoking.
Do isometric exercises to strengthen quadriceps muscles (knee OA).
Engage in weight-bearing exercise (walking, lifting weights), resistance-band exercises.
Avoid aggravating activities. Use cold or warm packs and ultrasound treatment.
Use walking aids. Patellar taping by physical therapist will reduce load on knees.
Alternative medicine: Use glucosamine supplements, SAM-e, tai chi exercises, acupuncture.
Degenerative Joint Disease (OA) Pharm Management
First line treatment =
Acetaminophen 325 to 650 mg every 4 to 6 hours (maximum 4 g/day) PRN. or
Tylenol 325 mg to 1,000 mg every 4 to 6 hours (maximum dose 4 g [4,000 mg] per 24 hours) PRN. Dehydration increases risk of hepatic adverse effects; drink a lot of water.
DJD 2nd Line Treatment
=
NSAIDs
If no relief with acetaminophen, switch to a short-acting NSAID.
Start with NSAIDs, such as ibuprofen (Advil), one to two tablets every 4 to 6 hours or naproxen (Aleve) BID or Anaprox DS one tablet every 12 hours PRN.
DJD Pharm Treatment Notes
(2) Rx = For added gastrointestinal (GI) protection (if long term)
If patient is at high risk for both __ bleeding and __ side effects, avoid NSAIDs.
- GI bleed risk factors: History of uncomplicated ulcer, aspirin, warfarin (Coumadin), peptic ulcer disease (PUD), platelet disorder
- Opioid analgesics: Avoid if possible (especially if patient is a recovering narcotic addict)
Age older than 75 years: Use topical (vs. oral) NSAIDs for treatment.
Rule out osteoporosis and order bone mineral density test (postmenopausal females, chronic steroid treatment males/females).
Add a proton-pump inhibitor (PPI; omeprazole) or misoprostol (Cytotec) = For added gastrointestinal (GI) protection (if long term)
If patient is at high risk for both GI bleeding and CV side effects, avoid NSAIDs.
- GI ____ risk factors: History of uncomplicated ulcer, aspirin, warfarin (Coumadin), peptic ulcer disease (PUD), platelet disorder
- _____ analgesics: Avoid if possible (especially if patient is a recovering narcotic addict)
Age older than 75 years: Use _____ (vs. oral) NSAIDs for treatment.
Rule out (1) and order (1) density test (postmenopausal females, chronic steroid treatment males/females).
Topical Medicine for DJD (OA)
(2)
NSAID: ______ gel (Voltaren Gel); apply to painful area and massage well into skin QID.
C______ cream: Apply to painful area QID. Avoid contact with eyes/mucous membranes.
Capsaicin comes from ____ peppers. Also used to treat _______ pain (e.g., post shingles).
Do not use on w____/abraded skin. Avoid sh______ afterward (so that it is not washed off).
NSAID: Diclofenac gel (Voltaren Gel); apply to painful area and massage well into skin QID.
Capsaicin cream: Apply to painful area QID. Avoid contact with eyes/mucous membranes.
Capsaicin comes from chili peppers. Also used to treat neuropathic pain (e.g., post shingles).
Do not use on wounds/abraded skin. Avoid bathing/showering afterward (so that it is not washed off).
Nonsteroidal Anti-Inflammatory Drug Risk
- _____ risk of (1):* Ketorolac (Toradol) and piroxicam (Feldene)
- _____ risk of (1)* Ibuprofen and celecoxib (Celebrex)
- ______ risk of (1) events:* Diclofenac and celecoxib at higher doses
- _____ risk of (1) events:* Naproxen
- Highest risk of GI bleeding:* Ketorolac (Toradol) and piroxicam (Feldene)
- Lowest risk of GI bleeding:* Ibuprofen and celecoxib (Celebrex)
- Highest risk of CV events:* Diclofenac and celecoxib at higher doses
- Lowest risk of CV events:* Naproxen
Classic Case of Gout
Middle-aged man presents with painful, hot, red, and swollen (1) joint of (1) toe (podagra). Patient is l_____ due to severe pain from weight bearing on affected toe. History of previous attacks at same site. Precipitated by ingestion of al____, m___, or s___food. Chronic gout has (1) (small white nodules full of urates on ears and joints). History of recurrent inflammatory arthritis (gout fl_____).
Middle-aged man presents with painful, hot, red, and swollen MTP joint of great toe (podagra). Patient is limping due to severe pain from weight bearing on affected toe. History of previous attacks at same site. Precipitated by ingestion of alcohol, meats, or seafood. Chronic gout has tophi (small white nodules full of urates on ears and joints). History of recurrent inflammatory arthritis (gout flare).
Ankylosing Spondylitis Labs
- ESR and CRP:* Slightly _____ ; RF is ____.
- Spinal radiograph:* Classic (1)**
- ESR and CRP:* Slightly elevated; RF is negative.
- Spinal radiograph:* Classic “bamboo spine”** (resembles bamboo; Figure 1).
- Painful arc test*
- =*
- Positive result =*
Starting with both arms down at the sides, ask patient to raise both arms (abduction) up towards head in an arch
Positive: Shoulder pain that occurs between 60 and 120 degrees of active abduction
- Jobe’s test (empty can test)*
- =*
Positive results =
This is a test for the strength of the supraspinatus muscle. Instruct patient to straighten arm at 90 degrees of abduction with 30 degrees of forward flexion, then internally rotate the shoulder. Tell patient to resist when examiner attempts to adduct the arm
Positive: Shoulder pain without weakness (tendinopathy), shoulder pain with weakness (suggests tendon tear)
Lateral Epicondylitis (Tennis Elbow) Complication
(1)
Patient will complain of? On what fingers?
What is the worst case scenario (“___ hand”)
Refer to (1) if you suspect this condition
Ulnar nerve neuropathy and/or palsy
(long-term pressure/damage).
Complaint of numbness/tingling on the little finger and the lateral side of the ring finger and weakness of the hand.
Worst-case scenario is development of a permanent deformity called “claw hand.”
Refer to neurologist if suspect ulnar nerve palsy.
Lateral and Medial Ankle Sprains
Most common mechanisms
- Lateral ankle sprain:*
- Medial ankle sprain:*
- It can cause an ______ fracture of the medial ______ due to pulling by the ruptured ____ ligament.
- Lateral ankle sprain:* The most common mechanism of injury is inversion of the plantar-flexed foot.
- Medial ankle sprain:* The most common cause is forced eversion of the ankle
- It can cause an avulsion fracture of the medial malleolus due to pulling by the ruptured deltoid ligament.
Grade III (Complete Rupture of Ligaments) X-ray
Ankle x-ray series is required if there is pain in the _____ zone and
- Inability to (1) immediately after the injury or
- Inability to ambulate at least ____ steps or
- Bone _____ over the ____rior edge or tip of the ____ malleolus or
- Bone ______ over the _____rior edge or tip of the _____ malleolus
Ankle x-ray series is required if there is pain in the malleolar zone and
- Inability to bear weight immediately after the injury or
- Inability to ambulate at least four steps or
- Bone tenderness over the posterior edge or tip of the medial malleolus or
- Bone tenderness over the posterior edge or tip of the lateral malleolus
Meniscus Tear (Knees)
Meniscus =
How do meniscus tears happen?
Meniscus = cartilaginous lining between certain joints that is shaped like a crescent, helps to cushion joints (act as shock absorbers and stabilizes the knee)
Tears in the meniscus result from trauma and/or overuse. Sports with higher risk are soccer, basketball, and football.
McMurray’s Test
=
Positive Test =
Pain is supine. The examiner holds the knee and palpates the joint line with one hand. The other hand holds the sole of the foot. Perform internal rotation of tibia and apply varus stress, then return the knee to maximal flexion, then extend the knee with external rotation of the tibia and apply valgus stress
Positive: Pain, clicking, or if the knee locks
Apley’s Test
=
Positive test =
Patient is prone with affected knee flexed at 90 degrees. Stabilize patient’s thigh (with examiner’s knee or hand). Press the patient’s heel downward (push heel toward the floor) while the foot is internally and externally rotated. The examiner is compressing the meniscus between the tibia and femur while twisting the foot.
Positive: Pain is elicited with the compression of the knee.
