Musculoskeletal

Question 1

cervical radiculopathy

Answer 1

• compression of the cervical nerve roots

* *most commonly affected C6 & C7

Question 2

radiculopathy

Answer 2

pathologic process affecting the nerve root.

causes: compressive vs noncompressive

Question 3

compressive cervical radiculopathy

Answer 3

cervical spondylosis & disc herniation

Question 4

non compressive radiculopathy:

Answer 4

infectious processes (especially herpes zoster and Lyme disease) nerve root infarction, root avulsion, infiltration by tumor, infiltration by granulomatous tissue, and demyelination

Question 5

symptoms of cervical radiculopathy

Answer 5

• -> 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.

Question 6

C-5

Answer 6

pain : neck shoulder scapula
numbness: lateral arm (indistribution of axillary nerve)
weakness: shoulder abduction, external rotation, elbow flexion, forearm supination
reflex affected: biceps, brachioradialis

Question 7

C-6

Answer 7

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

Question 8

C-7

Answer 8

pain : neck shoulder, middle finger, hand
numbness: index and middle finger, palm
weakness: elbow & wrist extension (radial) forearm pronation, wrist flexion
reflex affected: triceps

Question 9

spurling’s maneuver

Answer 9

+ 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.

Question 10

Abduction Relief Test

Answer 10

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

Question 11

neck pain & paresthesias exam

Answer 11

Abduction Relief test
palpate for tenderness muscle spasm lymphadenopathy
Assess sensory (dermatomes) and motor functions, DTRS

Question 12

neck pain & paresthesia diagnostics

Answer 12

• basis on hx & physical findings
• neuroimaging & electrodiagnostic testing
• MRI
• EMG
• Plain radiographs

Question 13

indications for neuroimaging & electrodiagnostic testing

Answer 13

• 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

Question 14

indications for MRI

Answer 14

currently the STUDY OF CHOICE in most patients for initial neuroimaging evaluation of the cervical spine

Question 15

indications of EMG

Answer 15

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

Question 16

indication for plain radiographs

Answer 16

rarely diagnostic in the setting on nontraumatic cervical radiography.

Question 17

treatment for neck pain & paresthesias (neck radiculopathy)

Answer 17

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

Question 18

indication for surgery : neck radiculopathy

Answer 18

–> 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

Question 19

cervical strain

Answer 19

muscle injury to the neck

Question 20

cervical sprain

Answer 20

ligamentous stretching-type injury

Question 21

whiplash

Answer 21

ligament is torn usually C7

Question 22

symptoms of cervical strain / sprain

Answer 22

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.

Question 23

examination of cervical strain/sprain

Answer 23

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

Question 24

diagnostics : cervical strain/sprain

Answer 24

AP lateral & open mouth (odontoid) radiographs are necessary if pt has hx of trauma or if the patient is elder

Question 25

treatment: cervical sprain/strain

Answer 25

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

Question 26

use of cervical collar

Answer 26

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

Question 27

why is the indication for physical therapy for cervical strain/sprain

Answer 27

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)

Question 28

cervical traction or massage therapy for cervical strain/sprain ?

Answer 28

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.

Question 29

Low back pain

Answer 29

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

Question 30

risk factor for back pain

Answer 30

``` 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 ```

Question 31

symptoms of Low Back Pain

Answer 31

pain that radiates to buttock & posterior thighs, may have difficulty standing erect or may need frequent position changes.

Question 32

physical findings on examination : low back pain

Answer 32

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

Question 33

what is Straight leg test?

Answer 33

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

Question 34

red flags for potentially serious underlying cause for low back pain

Answer 34

-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

Question 35

low back pain management

Answer 35

--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

Question 36

acute shoulder pain

Answer 36

follow episode of trauma. | dx: observation gentle palpation & x-ray

Question 37

unrelated to trauma shoulder pain ---> extrinsic

Answer 37

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

Question 38

Traumatic causes of shoulder pain include fracture & soft tissue injury:

Answer 38

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 .

Question 39

pain pattern : shoulder pain

Answer 39

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

Question 40

adhesive capsulitis

Answer 40

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

Question 41

cervical nerve root impingement produces :

Answer 41

SHARP PAIN radiating from the neck into the posterior shoulder area & arm

Question 42

range of motion testing

Answer 42

Appley Scratch test of external rotation | appley scratch test of internal rotation

Question 43

rotator cuff muscle strength testing

Answer 43

drop arm test empty can test push off test

Question 44

rotator cuff impingement testing:

Answer 44

hawkin's test | Neer's test

Question 45

Glenohumeral stability testing

Answer 45

sulsus sign | load and shift test

Question 46

Bicep tendon testing:

Answer 46

speed's test yergason's test biceps load test biceps tension test

Question 47

labral injury testing

Answer 47

O'Brien's test Biceps load test Biceps tension test Crank test

Question 48

Acromioclavical test

Answer 48

cross arm flexion test

Question 49

thorasic outlet syndrome tests

Answer 49

costoclavicular manuever Roo's test Adson test

Question 50

cervical spine tests

Answer 50

SPURLING'S TEST

Question 51

Bursitis of the olecranon (swelling)

Answer 51

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

Question 52

medial epicondylitis "golfer's elbow" pain

Answer 52

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

Question 53

lateral epicondylitis "tennis elbow" pain

Answer 53

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.

Question 54

treatment for olecranon bursitis | small mass & mild symptoms:

Answer 54

- -> 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.

Question 55

treatment for olecranon bursitis | more symptomatic bursitis

Answer 55

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

Question 56

treatment for olecranon bursitis: | septic bursitis

Answer 56

requires organ-specific antibiotics based on C&S of the aspirate the decompression either by surgical drainage or daily aspiration

Question 57

carpal tunnel syndrome

Answer 57

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

Question 58

symptoms of carpal tunnel syndrome

Answer 58

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

Question 59

carpal tunnel syndrome exam & tests

Answer 59

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

Question 60

carpal tunnel syndrome diagnostic tests

Answer 60

X-ray of limited ROM electrophysiologic testing can be used for confirmation

Question 61

treatment for mild - mod carpal tunnel syndrome

Answer 61

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

Question 62

unresponse to wrist splinting (carpal tunnel syndrome)

Answer 62

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

Question 63

Osteoarthritis

Answer 63

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

Question 64

osteoarthritis symptoms

Answer 64

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

Question 65

where does OA affect

Answer 65

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.

Question 66

Rheumatoid Arthritis

Answer 66

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

Question 67

feature of RA

Answer 67

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)

Question 68

RA

Answer 68

OSSIFICATION and DEFORMITY of joint EROSION of CARTILAGE

Question 69

HIP pain

Answer 69

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.

Question 70

neurovascular examination for hip pain

Answer 70

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

Question 71

diagnostic testing for hip pain

Answer 71

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

Question 72

hip pain management: DJD

Answer 72

tylenol NSAIDs glucosamine with or without chondroitin (not support by evidence) , Capsaicin

Question 73

hip pain management : bursitis

Answer 73

avoid activities that aggravate moist heat application ROM exercise NSAIDs

Question 74

knee pain

Answer 74

``` 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 <-- ```

Question 75

MENISCUS tear

Answer 75

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

Question 76

most common finding for meniscus tear

Answer 76

tenderness over medial or lateral joint line knee motion may be limited due to pain or an effusion positive McMurry sign

Question 77

what is McMurry sign

Answer 77

when flexion -circumduction maneuver is associated with painful click

Question 78

dx Meniscus tear

Answer 78

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

Question 79

management for Meniscus tear

Answer 79

RICE, crutches, improve strength of quadracepts traumatic severe tears--> refer

Question 80

ankle sprains: 1st degree

Answer 80

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

Question 81

ankle sprain : 2nd degree

Answer 81

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

Question 82

ankle sprain: 3rd degree

Answer 82

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.

Question 83

ankle sprain tests

Answer 83

``` crepitus = fracture squeeze test external rotation stress test anterior drawer test talar tilt test DX--> Xrays ```

Question 84

ankle sprain management

Answer 84

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

Question 85

fibromyalgia

Answer 85

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

Question 86

criteria to dx fibromyalgia

Answer 86

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

Question 87

fibromyalgia associated symptoms

Answer 87

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

Question 88

specific tests to dx fibromyalgia

Answer 88

base on hx and physical finding | no specific test

Question 89

management for fibromyalgia

Answer 89

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.