Musculoskeletal Flashcards
What questions should you ask when taking a musculoskeletal history?
Any discomfort or problems with your extremities or back?
Pain or stiffness could be caused by what?
Trauma (even micro-trauma), spasms, vascular insufficiency, or inflammation
Wasting or weakness could be caused by what?
Drugs, neuromuscular problems, age, or inactivity
Instability could be caused by what?
Arthritis, trauma, neuromuscular problems, or bad connective tissue
A thorough exam for each of the major joints should include what?
Inspection, palpation, assessment of range of motion, and special maneuvers to test for specific issues
The range of motion of the temporomandibular joint should be evaluated in which directions>
Opening and closing (three fingers should be able to be inserted between incisors when mouth is open wide), protrusion and retraction (bottom teeth can be placed in front of upper teeth during normal protrusion), and lateral (side-to-side) motion
What would you expect to see with anterior dislocation of the shoulder?
The rounded lateral aspect of the shoulder will appear flattened
What should you palpate when examining the shoulder?
Sternoclavicular joint, spine of the scapula, acromion, acromioclavicular joint, coracoid process, greater tubercle, biceps tendon in the intertubercular groove
What are the six motions of the shoulder girdle?
Internal and external rotation, abduction and adduction, flexion and extension
Restricted range of motion in the shoulder occurs with what?
Bursitis, capsulitis, rotator cuff tears or sprains, and tendinitis
How would you examine the bursae of the shoulder?
By first passively extending the humerus by lifting the elbow posteriorly, rotating the structures so they are anterior to the acromion
How would you examine the SITS muscles?
Supraspinatus is directly superior to the spine of the scapula, infraspinatus is directly inferior to the spine of the scapula, teres minor is inferior to the infraspinatus, and subscapularis inserts anteriorly and is not palpable
Localized tenderness during palpation of the shoulder joint arises from what?
Subacromial or subdeltoid bursitis, among other things
Tenderness and effusion during palpation of the shoulder joint suggests what?
Synovitis of the glenohumeral joint
Tenderness over the SITS muscle insertions and inability to abduct the arm is seen in what?
Sprains, tears, and tendon rupture of the rotator cuff
Injury of which SITS muscle is most common?
Supraspinatus
What does the painful arc test examine?
Subacromial bursa and supraspinatus
When would the painful arc test be considered positive?
When pain occurs between 60-120 degrees of abduction with less pain at the beginning and end ranges of motion
What would you instruct the patient to do during the painful arc test?
To slowly abduct the arms with thumbs pointing upwards
What does the external rotation lag test examine?
Supraspinatus and infraspinatus
What would you instruct the patient to do for the external rotation lag test?
With the patient’s arm flexed to 90 degrees with the palm up, the physician rotates the arm into full external rotation and asks the patient to keep the arm in that position
When would the external rotation lag test be considered positive?
When the patient cannot hold the position
What does the internal rotation lag test examine?
Subscapularis
How would you perform the internal rotation lag test?
While standing behind the patient, bring the dorsum of the hand behind the low back with the elbow flexed to 90 degrees. Grip the wrist and lift the hand off the back and ask the patient to keep the hand in this position as you release the wrist
When would the internal rotation lag test be considered positive?
When the patient cannot hold the position
What does the drop-arm test examine?
Supraspinatus
How would you perform the drop-arm test?
Abduct the patient’s arm to around 120 degrees and then ask them to lower it slowly
What does the external rotation resistance test examine?
Infraspinatus
How would you perform the external rotation resistance test?
Ask the patient to adduct and flex the arm to 90 degrees with the thumb 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
Swelling over the olecranon process is found in what?
Olecranon bursitis
What should you palpate in the elbow?
The olecranon process, the epicondyles, and the grooves between the epicondyles and the olecranon process
Tenderness distal to the lateral epicondyle may be due to what?
Lateral epicondylitis (tennis elbow); fairly common
Tenderness distal to the medial epicondyle may be due to what
Medial epicondylitis (pitcher’s or golfer’s elbow); less common
What ranges of motion should you test in the elbow?
Flexion and extension at the elbow, pronation and supination of the forearm
Local swelling of the hand suggests what?
A ganglion cyst
Diffuse swelling of the hand is common in what?
Arthritis or infection
What is a Dupuytren contracture?
A thickened fibrotic cord develops between the palm and the area proximal to the fourth finger and possibly the little finger near the distal palmar crease, limiting finger extension
What is trigger finger?
Caused by a painless nodule in the flexor tendon in the palm, near the metacarpal hand, which is too big to enter easily into the tendon sheath during extension of the fingers from a flexed position
What does thenar atrophy suggest?
A median nerve disorder, like carpal tunnel syndrome
What does hypothenar atrophy suggest?
An ulnar nerve disorder
What should you palpate in the wrist?
The distal radius and ulna on the lateral and medial surfaces, the groove of each wrist joint with your thumbs on the dorsum of the wrist, the radial styloid bone and the anatomical snuffbow
What is the anatomical snuffbox formed by?
The abductor and extensor muscles of the thumb
What are the ranges of motion of the wrist?
Flexion and extension, radial and ulnar deviation
How would you perform the Finkelstein’s test?
Ask the patient to grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation
Tenderness over the extensor and abductor tendons of the thumb suggests what?
de Quervain’s tenosynovitis or gonococcal tenosynovitis
What symptoms would cause you to test for carpal tunnel syndrome?
Complaints of dropping objects, inability to twist lids off jars, aching at the wrist or the forearm, and numbness of the first three digits
What signs would cause you to test for carpal tunnel syndrome?
Thenar atrophy and decreased sensation in the median nerve distribution
How would you test thumb abduction?
Ask the patient to raise the thumb straight up as you apply downward resistance, with weakness of thumb abduction indicating a positive test
How would you test Tinel’s sign?
By tapping lightly over the course of the median nerve in the carpal tunnel, with aching and numbness in the median nerve distribution indicating a positive test
How would you test for Phalen’s sign?
By asking the patient to hold the wrists in flexion for 60 seconds, with numbness and tingling in the median nerve distribution within 60 seconds indicating a positive test
What should you palpate in the hand?
The MCP joints, the medial and lateral aspects of each IP joint
What are the ranges of motion of the fingers?
Flexion and extension, abduction and adduction
A normal gait has what characteristics?
The width of the base should be 2-4 inches from heel to heel, with a smooth continuous rhythm with little pelvic tilt
A wide base in a patient’s gait suggests what?
Cerebellar disease or foot problems
Abductor contraction does what during gait?
Stabilizes the pelvis and helps maintain balance, raising the opposite hip
Leg shortening and external rotation suggest what?
Hip fracture
How do lack of knee flexion and drop foot affect gait?
They interrupt the smooth pattern of gait with circumduction of the extremity
What does focal tenderness over the trochanter suggest during palpation of the hip?
Trochanteric bursitis
Tenderness in the groin area during palpation of the hip may be due to what?
Synovitis of the hip joint, bursitis, or possibly a psoas abscess
Tenderness in the area of the ischial tuberosity during palpation of the hip may indicate what?
Ischiogluteal bursitis or “weaver’s bottom”
What are the ranges of motion of the hip?
Flexion and extension, abduction and adduction, internal and external rotation
Stumbling or “giving way” of the knee during heel strike suggests what?
Quadriceps weakness or abnormal patellar tracking
Flexion contracture of the knees is seen in what?
Limb paralysis or hamstring tightness
Swelling over the patella suggests what?
Prepatellar bursitis
Swelling over the tibial tubercle suggests what?
Infrapatellar, or if more medial, anserine bursitis
A medial meniscus tear will have point tenderness in what area?
At the medial soft-tissue depression along the upper edge of the tibial plateau (palpation of the tibiofemoral joint and medial meniscus)
Tenderness over the patellar tendon or inability to extend the knee suggests what?
Partial or complete tear of the patellar tendon
Pain with compression and with patellar movement during quadriceps contraction suggests what?
Chondromalacia (patellofemoral syndrome), which is associated with degeneration of the patellar cartilage
The bulge sign is used to test for what?
Minor effusions of the knee joint
The balloon sign is used to test for what?
Major effusions of the knee joint
Ballotting the patella is used to test for what?
Large effusions of the knee joint
Tenderness and thickening of the tendon above the calcaneus suggests what?
Achilles tendinitis
A defect in the tendon above the calcaneus with tenderness and swelling suggests what?
A ruptured Achilles tendon
What else can indicate a ruptured Achilles tendon, besides a defect in the tendon with tenderness and swelling?
Absence of plantar flexion of the foot with calf squeeze
Supination of the ankles occurs with what type of foot arch?
High foot arch
Over pronation of the ankles occurs with what type of foot arch?
Low foot arch (flat foot)
Focal heel tenderness on palpation of the plantar fascia suggests what?
Plantar fasciitis, seen in prolonged standing or heel-strike
Tenderness along the posterior medial malleolus suggests what?
Posterior tibial tendinitis, which causes flat feet
After trauma, the inability to bear weight and tenderness over the posterior aspects of either malleolus (especially medial) is suspicious for what?
Ankle fracture
What are the ranges of motion for the ankle?
Inversion and eversion, dorsiflexion and plantarflexion
