Musculoskeletal Flashcards
cervical radiculopathy
- compression of the cervical nerve roots
* *most commonly affected C6 & C7
radiculopathy
pathologic process affecting the nerve root.
causes: compressive vs noncompressive
compressive cervical radiculopathy
cervical spondylosis & disc herniation
non compressive radiculopathy:
infectious processes (especially herpes zoster and Lyme disease) nerve root infarction, root avulsion, infiltration by tumor, infiltration by granulomatous tissue, and demyelination
symptoms of cervical radiculopathy
- -> neck pain & radicular pain associated with numbness & paresthesia in the upper extremity in the distribution of involved root.
- reflexes are typically reduced in radiculopathy of the C5 C6 or C7 nerve roots, but there are no standard reflexes that reflect the distribution of the C8 and T1 nerve roots
- -> muscle spasm or fasciculations in the involved myotomes may occur
- -> weakness, lack of coordination, changes in handwriting, grip strength, dropping objects from the hand, pain in radiating into the paraspinal and scapular regions (typical of those with root pressure above C5)
- ->Pts may report they can relieve the pain by placing the hands on top of their head as this decreases tension on the involved nerve root.
C-5
pain : neck shoulder scapula
numbness: lateral arm (indistribution of axillary nerve)
weakness: shoulder abduction, external rotation, elbow flexion, forearm supination
reflex affected: biceps, brachioradialis
C-6
pain: neck, shoulder, scapular, lateral arm, lateral forearm, lateral hand
numbness: lateral forearm, thumb and index finger
weakness: shoulder abduction, external rotation, elbow flexion, forearm supination and pronation
reflex effected: biceps, branchoradials
C-7
pain : neck shoulder, middle finger, hand
numbness: index and middle finger, palm
weakness: elbow & wrist extension (radial) forearm pronation, wrist flexion
reflex affected: triceps
spurling’s maneuver
+ if limb pain or paresthesias are produced (the test should then be stopped)
- production of neck pain alone in response to the Spurling maneuver is nonspecific and constitutes a negative test
- The Spurling test has high specificity for the presence of cervical radiculopathy , but its sensitivity is low to moderate. A positive Spurling test is helpful for supporting the dx of cervical radiculopathy, but negative test does not rule out radicular pathology
**never perform in patients who may have instability of cervical spine, (rheumatoid arthritis, cervical malformation or metastatic disease, since it may cause further injury to the spine. In addition, it should not be perfomed when associated cervical myelopathy is suspected.
Abduction Relief Test
the pt is asked to lift the symptomatic arm above the head, resting the hand on the top of the head.
the test is + if the patient has a decrease or disappearance of the radicular symptoms with this maneuver
neck pain & paresthesias exam
Abduction Relief test
palpate for tenderness muscle spasm lymphadenopathy
Assess sensory (dermatomes) and motor functions, DTRS
neck pain & paresthesia diagnostics
- basis on hx & physical findings
- neuroimaging & electrodiagnostic testing
- MRI
- EMG
- Plain radiographs
indications for neuroimaging & electrodiagnostic testing
- PERSISTENT SYMPTOMS that do not resolve with four to six weeks of conservative therapy
- significant neurologic findings or localizing symptoms are present, including myotomal weakness or myelopathy
indications for MRI
currently the STUDY OF CHOICE in most patients for initial neuroimaging evaluation of the cervical spine
indications of EMG
The diagnosis of radiculopathy is usually CONFIRMED by needle electromyography (EMG) which frequently reveals a myotomal pattern of denervation.
nerve conduction studies alone are not sensitive for radiculopathy.
performing electrodiagnostic testing when symptoms have been present for less than 3 weeks reduces the sensitivity of the test
indication for plain radiographs
rarely diagnostic in the setting on nontraumatic cervical radiography.
treatment for neck pain & paresthesias (neck radiculopathy)
Conservative treatment for pt with cervical radiculopathy who have clear radicular pain and symptoms of paresthesia, numbness, or nonprogressive neurologic deficits
—>Oral analgesics (eg. NSAIDS) avoidance of provocative activities, add short course of oral PREDNISONE if pain is severe
—>once the pain is tolerable, initiate PT with exercise & gradual mobilization.
With confirmed cervical radiculopathy with severe or disabling pain despite a course of conservative therapy, & who do not have a progressively worsening neurologic deficit, recommendation is use of epidural steroid injections rather than surgery
indication for surgery : neck radiculopathy
–> symptoms & signs of cervical radiculopathy
cervical nerve root compression by MRI or CT myelography at the appropriate side & level(s)
Persistence of radicular pain despite nonsurgical therapy for at least 6-12 weeks, or progressive motor weakness that impairs function
cervical strain
muscle injury to the neck
cervical sprain
ligamentous stretching-type injury
whiplash
ligament is torn usually C7
symptoms of cervical strain / sprain
spontaneous onset pain
pain from the base of skull to the cervicothoracic junction, may report pain in the region of the sternocleidomastoid muscles and/or the trapezius muscles.
pain is worsen w/ motion & may be accompanied by paraspinal spasm
occipital headaches may occur in the early phase & may persist longer than pain following strains & sprains of spontaneous onset
may report increase irritability fatigue sleep disturbance and difficulty concentrating.
examination of cervical strain/sprain
tenderness in paraspinous muscles, trapezil, sternocleidomastoid muscles, spinous processes, interspinous ligaments, and/or the medial border of the scapula
limited ROM is common (rotation, lateral bending, and/or flexion & extension)
pain is often noted in extremes of motions
neuro exam is usually normal
diagnostics : cervical strain/sprain
AP lateral & open mouth (odontoid) radiographs are necessary if pt has hx of trauma or if the patient is elder
treatment: cervical sprain/strain
mild-moderate axial pain improve in 2-3 weeks
- ->posture modification, especially in sleep
- ->home exercise
- ->acetaminophen or NSAIDs medications
- ->mild OPIOID for short-term treatment for severe pain
- ->low dose tricyclic antidepressant at HS for more chronic pain which interferes with sleep (AMITRIPTYLINE or NORTRIPTYLINE)
- ->muscle relaxant low dose in day time for severe muscle spasm (FLEXERIL)
cervical collar
Physical therapy
use of cervical collar
do not use for prolonged periods of time
cervical collars may be helpful to alleviate severe pain, but should be worn for 3 hour or less, and no more than one to two weeks
why is the indication for physical therapy for cervical strain/sprain
proprioception, strength training, & therapeutic exercise or manual therapy with mobilization for patients with neck pain that is persisting despite home exercises (not recommended to prescribe spinal manipulation as the sole treatment, especially for older adults)
cervical traction or massage therapy for cervical strain/sprain ?
DO NOT PRESCRIBE !!!
instead consider trials of trigger point injections, TENS, cervical medial branch blocks, & percutaneous radiofrequency neurotomy for appropriate patients who have not responded to measures discussed.
Low back pain
low back pain is the second most common symptomatic reason for clinician visits (followed by URTI)
84% adults have low back pain
common cause of disability
by 50 y.o –80-90% has evidence of DDD
risk factor for back pain
smoking obesity older age female physically strenuous work sedentary work psychologically strenuous work low educational attainment worker comp insurance job dissatisfaction psychological factors: such as somatization disorder anxiety and depression
symptoms of Low Back Pain
pain that radiates to buttock & posterior thighs, may have difficulty standing erect or may need frequent position changes.
physical findings on examination : low back pain
anatomic abnormalities such as scoliosis (lateral spinal curvature) or kyphosis ( spinal curvature with posterior convexity)
vertebral tenderness
Straight leg test
Range of motion
Sensory (along dermatomes) & motor function, DTRs
abdominal exam
what is Straight leg test?
useful to confirm radiculopathy
–> pt. supine. examiner raises pt’s extended leg with the ankle dorsiflexed, being careful that the patient is not actively “helping” in lifting the leg.
+ when sciatica is reproduced between 10-60 degrees of elevation
red flags for potentially serious underlying cause for low back pain
-trauma cumulative trauma
-unexplained weight loss
age >50 especially women, and males with osteoporosis or compression fracture
unexplained fever, history of urinary or other infections
immunosuppression, or DM
hx of cancer
IV drug use
prolonged use of corticosteroid osteoporosis
age >70
focal neurologic deficit (s) w/ progressive or disabling symptoms, cauda equina syndrome
duration longer than six weeks
prior surgery
low back pain management
–usually self limited: 90% resolve in 1-6 weeks
-pharmacology : tylenol, NSAIDs, muscle relaxants
-Activity: as tolerated, bed rest no longer than 2 days; walking important. wt loss, physical activity, exercise x3o minute per day; stop smoking
DO NOT advise pt with acute low back pain to remain at bed res
RTC 2 week if problem persists– sooner if worsens
acute shoulder pain
follow episode of trauma.
dx: observation gentle palpation & x-ray
unrelated to trauma shoulder pain —> extrinsic
pain that is poorly localize or vaguely described is often extrinsic
(1) neurologic: cervical nerve root compression (C5 &C6) supraspinatus nerve compression, brachial plexus lesions, herpes zoster, spinal cord lesion, cervical spine disease
(2) abdominal: hepatobiliary disease
diaphragmatic imitation (splenic injury, rupture ectopic pregnancy, perforated viscus)
(3) cardiovascular: MI, axillary vein thrombosis , thoracic outlet syndrome
(4) thoracic : upper lobe pneumonia, apical lung tumor, pulmonary embolus
Traumatic causes of shoulder pain include fracture & soft tissue injury:
acute symptoms (less than 2 weeks duration) in patients with hx of recent shoulder trauma are typically d/t an acromioclavicular (AC) separation, glenohumeral dislocation, fx or rotator cuff tear .
pain pattern : shoulder pain
anterolateral shoulder pain aggravated by reaching overhead is a common pain pattern. often associated with impingement syndrome and the various stages of rotator cuff tendinopathy
adhesive capsulitis
frozen shoulder –> is the most likely dx when px is accompanied by stiffness and a significant loss of movement in both active and passive motion of the shoulder
cervical nerve root impingement produces :
SHARP PAIN radiating from the neck into the posterior shoulder area & arm
range of motion testing
Appley Scratch test of external rotation
appley scratch test of internal rotation
rotator cuff muscle strength testing
drop arm test
empty can test
push off test
rotator cuff impingement testing:
hawkin’s test
Neer’s test
Glenohumeral stability testing
sulsus sign
load and shift test
Bicep tendon testing:
speed’s test
yergason’s test
biceps load test
biceps tension test
labral injury testing
O’Brien’s test
Biceps load test
Biceps tension test
Crank test
Acromioclavical test
cross arm flexion test
thorasic outlet syndrome tests
costoclavicular manuever
Roo’s test
Adson test
cervical spine tests
SPURLING’S TEST
Bursitis of the olecranon (swelling)
pt. who complain of elbow swelling most often have olecranon bursitis
warmth & redness that accompany the swelling and the rapidity with which the symptoms appear are clues to distinguish the underlying cause (usually trauma, sepsis , or gout)
The ability of the pt to extend and flex the elbow completely generally excludes an intrarticular process as the cause of the elbow pain
medial epicondylitis “golfer’s elbow” pain
medial elbow pain is the second most common complaint at the elbow. it frequently arise either from the medical epicondyle or the ulner nerve as it travels through the cubital tunnel
as with lateral epicondylitis the pain of medical epicondylitis is well localized and is aggravated by actions that contract the wrist flexors, such as lifting or repetitious use of the forearm and wrist
lateral epicondylitis “tennis elbow” pain
lateral elbow pain is the most common complaint at the elbow. the source of pain may be the lateral epicondyle, the radiohumeral uoint, or referred pain from the shoulder or neck
the pain of lateral epicondylitis (tennis elbow) is typically well localized (the patient often points to the lateral epicondylar process) and is aggravated by activity that contracts the wrist extensors, including repetitious use of the forearm and wrist and shaking hands.
treatment for olecranon bursitis
small mass & mild symptoms:
- -> bursitis should be left alone or tx symptomatically with activity modification and possible NSAIDs
- ->wear an elbow pad & avoiding hyperflexion against hard surfaces may improve symptoms.
treatment for olecranon bursitis
more symptomatic bursitis
undergo aspiration of the bursa, followed by gram stain & culture of suspicious fluid
if no indication of septic bursitis a compression bandage consisting of circular foam, 8cm in diameter and an elastic warp should be applied.
reassess pt in 2-7 days
treatment for olecranon bursitis:
septic bursitis
requires organ-specific antibiotics based on C&S of the aspirate the decompression either by surgical drainage or daily aspiration
carpal tunnel syndrome
entrapment of the median nerve at the wrist
most common compression neuropathy in the upper extremity
most common in middle-aged or pregnant women
conditions that reduce the size or space of the carpal tunnel can result in compression of the median nerve
–>precipitation tenosynovitis of the adjacent flexor tendons (repetitive overuse trauma, RA) tumors pregnancy DM & thyroid dysfunction
symptoms of carpal tunnel syndrome
reports vague aching that radiates into the thenar area
aching may be perceived in the proximal forearm an pain can extend into the shoulder
pain is typically accompanied by paresthesias or numbness in the median distribution (thumb index finger long finger, or some combination of those )
often symptoms are worse at night
dropping objects can’t open jars or twist lids
carpal tunnel syndrome exam & tests
inspect for sensation in the fingers, swelling redness nodules, deformity muscle atrophy of thenar eminence; active ROM
-palpate for tenderness
PHALEN’S sign : most useful clinical test
TINELS sign
carpal tunnel syndrome diagnostic tests
X-ray of limited ROM electrophysiologic testing can be used for confirmation
treatment for mild - mod carpal tunnel syndrome
splinting
glucocorticoids injected into carpal tunnel
oral glucocorticoids
carpal bone mobilization and yoga may also be beneficial
Referral to an occupational therapist with subspecialty certification in hand therapy may improve outcomes
unresponse to wrist splinting (carpal tunnel syndrome)
inject methylprednisone 40mg if declines injection try oral prednison 20mg daily for 10-14 days
surgical decompression - moderate to severe CTS that is refractory to conservative measures
Osteoarthritis
result from multiple factors include joint integrity, genetics, local inflammation, mechanical forces, and cellular and biochemical processes
common: >40 y.o.
pain is exacerbated by activity and relieved by rest
osteoarthritis symptoms
stiffness (resolves in the morning less than 30 minutes after awakening; the recurrence of stiffness that may occur with inactivity is termed gelling
tenderness on palpation, typically in the absence of inflammation, crepitus, bony enlargement, decreased range of motion; and malalignment; synovial effusion, if present show mild pleocytosis, normal viscosity, and modestly elevated protein
where does OA affect
all joints but not equally, it has a predilection for the FINGERS, KNEES, HIPS, SPINE, and rarely the elbows, wrists and ankles
OA is generally slowly progressive, although it stabilizes in some pts. The course of those with progressive disease is usually one of intermittent worsening.
Rheumatoid Arthritis
chronic systemic inflammatory disorder of unknown etiology that primarily involves joints
symmetrical
progresses from periphery to more proximal joints and pts who do not fully respond to tx result in significant locomotor disability within 10-20 years
feature of RA
morning stiffness for at least one hour and present for at least 6 weeks
swelling of 3 or more joints for at least 6 weeks
swelling of wrist metacarphalangeal or proximal interphalangeal joints for at least 6 weeks
symmetric joint swelling
hand x-ray changes typical of RA that include erosions or bony decalcification
Rheumatoid subcutaneous nodules
Rheumatoid factors or anti-citrullinated peptide/protein antibodies
elevated acute phase reactants (erythrocyte sedimentation rate or C-reactive protein)
RA
OSSIFICATION and DEFORMITY of joint EROSION of CARTILAGE
HIP pain
largest joint in the body
- *increase pain with or after use (particularly with weight bearing) and improvement with rest is the the hallmark of a structural joint problem, particularly osteoarthritis
- *constant pain esp. at night suggests an INFECTIOUS inflammatory or neoplastic process.
neurovascular examination for hip pain
should be perform:
sensory testing of the feet for light touch, pinprick, and deep pain sensation are combined with motor testing of dorsiflexion and plantarflexion to determine the integrity of lower extremity neurologic function
The dorsalis pedis and posterior tibialis arteries are palpated in patients with suspected aortiliac vascular occlusive disease
diagnostic testing for hip pain
PLAIN RADIOGRAPH should be performed with acute hip pain to exclude fx or with pt with mod-severe pain
MRI may be necessary when hx physical ex. and plain radiography are inconclusive
hip pain management: DJD
tylenol NSAIDs glucosamine with or without chondroitin (not support by evidence) , Capsaicin
hip pain management : bursitis
avoid activities that aggravate moist heat application ROM exercise NSAIDs
knee pain
modified hinge joint, weight bearing 3 bones 5 major tendons 4 major ligaments 2 menisci (many site for injury) most knee complaints are r/t exercise or sports MENISCUS tears-->most common of all knee injuries <--
MENISCUS tear
locking or giving away pain
popping stiffness swelling
reports twisting injury –> immediately after injury person can walk and may continue to play
Pain on medical or lateral side of the knee particularly with twisting or squatting activities
most common finding for meniscus tear
tenderness over medial or lateral joint line
knee motion may be limited due to pain or an effusion
positive McMurry sign
what is McMurry sign
when flexion -circumduction maneuver is associated with painful click
dx Meniscus tear
trauma or effusion: X-Ray : AP, lateral, axial patellofemoral views
Chronic: AP & lateral views should be weight bearing
Definitive test: MRI done only if doubt or surg is planned –>referral has been made
management for Meniscus tear
RICE, crutches, improve strength of quadracepts
traumatic severe tears–> refer
ankle sprains: 1st degree
results from mild stretching of a ligament with microscopic tears
mild swelling and tenderness
no joint instability on examination, and the pt is able to bear wt and ambulate with minimal pain
ankle sprain : 2nd degree
most severe injury involving an incomplete tear of a ligament
mod pain, swelling tenderness and ecchymosis
mid-mod joint instability on exam w some restriction of the range of motion and loss of function
weight bearing and ambulation are painful
ankle sprain: 3rd degree
involves a complete tear of a ligament
severe pain, swelling tenderness and ecchymosis
significant mechanical instability on exam and significant loss of function an dmotion
patients are unable to bear weight or ambulate.
ankle sprain tests
crepitus = fracture squeeze test external rotation stress test anterior drawer test talar tilt test DX--> Xrays
ankle sprain management
to prevent chronic pain & instability
(1) limit inflammation & swelling & maintain ROM –> RICE
use crutches until they are able to walk with normal gait
Cryotherapy applied as ice or cold water immersion is recommended for 15 -20 min every 2-3 hours for the first 48 hours or until swelling is improved whichever come first
compression with elastic bandage or air cast/brace to minimize swelling should be applied early
the injured ankle should be kept elevated above the level of the heart to further alleviate swelling
NSAIDs
fibromyalgia
chronic generalized musculoskeletal pain
–> mostly women
–>dx relies on hx research supported tender point criteria
patho:
altered central pain processing
elevated CSF substance P altered pain inhibitory mediator serotonin, norepinephrine; dysregulated response to HPA axis
criteria to dx fibromyalgia
pain in the axial skeleton and all four quadrants for 3 or more months
excessive tenderness to 4kg of point pressure in 11 of 18 specific muscle tendon sites
pain from sources that do not usually cause pain
if painful to others, then exaggerated to patient
pain worsens with repetition of stimulus
pain & stiffness uniform through out the day
fibromyalgia associated symptoms
sleep disturbance, fatigue, diminished cognitive function, lightheadedness/dizziness, palpitations
Co-morbiditites: depression, anxiety, chronic fatigue syndrome, migraine, IBS, restless legs, TMJ dysfunction, female urethral syndrome
specific tests to dx fibromyalgia
base on hx and physical finding
no specific test
management for fibromyalgia
non-pharm:
exercise (aerobic)
cognitive behavioral therapy
strength training, acupuncture, hypnotherapy biofeedback medicinal baths
pharm:
NSAID (not effective)
tricyclic antidepressant: initiating with low dose (AMITRIPTYLINE) to improve sleep
CYCLOBENZAPRINE is alternative to amitriptyline
alpha-2delta ligand pregabalin (LYRICA)
serotonin-norepinephrine reuptake inhibitor duloxetine (CYMBALTA) or (milnacipran)
- *opioids chronic use will cause neuroadaptive changes that maintain or enhance central sensitivity to pain
- *no single therapy control symptoms.