Musculoskeletal Flashcards
Carpal Tunnel Syndrome S/S
- Aching pain radiates to FA
- Paresthesia in median distribution
- Nocturnal paresthesia
- Muscle weakness/atrophy (longstanding)
Carpal Tunnel Sensory exam
- Radial: Volar thumb
- Ulnar: 5th finger
- Median: 1st dorsal web space
Carpal tunnel motor exam
- Radial: wrist extension
- Ulnar: Hand intrinsics
- Median: Opposition thumb and 5th finger
Phalen’s Test
- Wrist in max flexion for 30-60sec
- Paresthesia in median distribution
- Thumb, index, long finger, radial border of ring finger
Tinel’s Sign
- tap over transverse carpal ligament, wrist in extension
* tingling in median distribution
Carpal tunnel Tx
- NSAIDs
- Reduce repetitive motions
- Ergonomics
- Wrist splint at night
- Steroid injection
- Surgery
Lateral tendinosis (Tennis elbow) S/S
- pain over epicondyle and back of forearm
- Lifting with palm down increases pain
- may or may not be swelling
Tennis elbow treatment
- NSAIDs (2wk)
- Counterforce brace
- Ice/Heat
- Wrist splint
- Short or long arm cast
- Isometric toning exercise
- Steroid injection
Impingement syndrome S/S
- Painful overhead ROM
- Impingement and inflammation of rotator cuff and bursa b/n humerus and lateral structures
- gradual onset of anterolateral pain that may radiate to elbow or hand
- crepitus and pain through 60-120 abduction arc
- ## Nocturnal symptoms
Neer Test
1) Stabilize scapula
2) Passively flex arm
3) Pain is positive sign
Hawkin’s Test
1) Stabilize scapula
2) Abduct shoulder to 90-degrees
3) Internally flex shoulder to 30-degrees
4) flex elbow to 90-degrees
5) Internally rotate elbow
6) Pain is a positive test
Impingement Tx
- NSAIDs (14d)
- Rest from offending activity
- Subacromial injection
- PT
- consider referral
Cervical spine vs. shoulder vs radiculopathy
- Cervical Disk Dz: More comfortable with hand on head
- Intrinsic shoulder Dz: More comfortable with arm at side
- Radicular neck and arm pain/paresthesia:
- C5=base of neck & lateral shoulder
- C6=thumb and radial arm
- C7=Index/long fingers and triceps
- C8=Ring/little fingers and ulnar arm
Spurling Test
- Extend neck and tilt to each side
- Neck pain is not a positive sign
- Pain or paresthesia in shoulder/arm suggests radiculopathy
Rotator cuff tear S/S
- More common >40yo
- 95% 2/t impingement
- Night pain with inability to turn to affected side
- Weakness with overhead activity
- Pain/weakness in 60-120 abduction arc
- PROM > AROM
- Tenderness over greater tuberosity
Drop arm test (Supraspinatus)
1) Abduct arms to 90-degrees
2) internally flex shoulders to 30-degrees
3) Internally rotate shoulder until thumbs point down
4) Inability to hold arms up is a positive test
Other tests for rotator cuff tear
- Empty can test (supraspinatus)
- Push off test (Subscapularis)
- flexed elbows abduction vs. resistance (teres minor and infraspinatus)
Rotator Cuff Tx
- Minor tears=no Tx
- Avoid offending activity
- PT
- NSAIDs, APAP, tramadol (controversy about NSAIDs)
- Subacromial injection
- Surgery (complete tears)
Frozen Shoulder (Adhesive Capsulitis) S/S
- Insidious onset of decreased AROM and PROM
- Contracture of joint capsule
Frozen Shoulder Tx
- Avoid immobilization
- NSAIDs
- Analgesic injections (reduce pain for PT)
- PT
- Manipulation under anesthesia
- Arthroscopic capsular release
Stenosing Tenosynovitis (Trigger finger) S/S
- Inflammation of flexor tendon sheath at the A1 pulley (Often thumb, ring, and long fingers)
- Risk: DM, RA, >40yo
- Pain and catching with finger flexion
- Tenderness at metacarpal head
- May awaken with finger “locked”
Trigger finger Tx
- Splint finger in extension 10-14d
- NSAID’s
- Restrict gripping and pinching
- Buddy taping
- Steroid injection
- Surgery
Osteoarthritis of Hand S/S
- DIP and PIP joints most often involved with bony nodules
- Stiffness and loss of motion
- MCP less commonly involved
RA of hand S/S
- MCP and wrist most commonly involved
- Morning pain and extended stiffness
- Fusiform swelling of multiple joints
- Synovitis may be associated with tendon rupture
OA and RA of hand Tx
- APAP
- NSAIDs
- Temporary splinting
- Topical therapies
- Corticosteroid injections (very helpful in RA)
Low Back pain s/s
- lower back pain that radiates towards buttocks
- May radiate to lower leg
Back pathology by age/posture
- 20-40yo: Lumbar strain - Prefer to sit (NOT stand or flex)
- 30-50yo: Disk Dz - Prefer to stand (NOT flex)
- > 50yo: OA - prefer to bend (NOT stand or extend)
- Spinal stenosis - Prefer to stoop
Straight leg raise
- Elevate leg until pt c/o pain (~45-degrees)
- Dorsiflex ankle: back pain, radicular sx?
- Plantarflex ankle: Relieves sciatic tension, increased pain may indicate nonorganic cause
- Compare to sitting SLR
- Consider contralateral SLR
Flip Sig
1) Pt seated w/hands on edge of table
2) Ask about knee pain
3) extend knee
4) sciatic tension will cause pt. to flip back in acute pain
5) No pain makes sciatic radiculopathy unlikely
Acute low back pain Tx
- NSAIDs 10-14d
- PT
- Muscle relaxants qhs for sleep
- Ice/Heat
- Trigger point injection
Chronic Low Back Pain s/s
- Associated with Degenerative disk dz
- LBP >3mo
- May be recurrent or unremitting
- Radaites to one or both buttocks
- Aggravated with ROM
- may be associated with intermittent sciatica and mood disturbances
Chronic low back pain Dx
- Films: may show osteophytes and reduced intervertebral height
Chronic low back pain Tx
- NSAIDs or Tramadol
- Tx depression
- PT, Yoga, massage, acupuncture
- Weight reduction
- Smoking cessation
Lumber radiculopathy (herniation) S/S
- Most often in L5 or S1
- Often abrupt and associated with LBP
- Aggravated by sitting, walking, standing, coughing
- L1-3: radiates to anterior thigh
- L3-4: weak ADF, Asymmetric knee reflex
- L4-5: Weak EHL, numb 1st web space
- L5-S1: Weak gastroc, asymmetric ankle reflex
Lumbar radiculopathy Dx
- Plain films may show age appropriate changes
- MRI
Lumbar radiculopathy Tx
- NSAID’s
- Steroids PO
- Limit sitting
- 1-2d bedrest
- Short course of narcotic analgesia/muscle relaxants
- PT
Lumbar spinal stenosis s/s
- narrowing of 1+ levels of spinal canal with subsequent nerve compression
- Usually 60+yo
- Uncommon at L5-S1
- May be sudden or gradual
- fatigue and weakness proximal-to-distal pattern
- Aggravated by walking or standing
- Relieved by sitting or lying
Lumbar Stenosis exam
- No weakness of BLE
- poor proprioception/Romberg
- Peripheral pulses +2
- +1 DTRs
- Narrowing of intervetebral disks on XR
- MRI reveals narrowing of canal with nerve root compression
Vascular vs. Neurogenic LE pain
- Vascular: Fixed distance, relief with standing, pain with uphill walking, Pain with biking, absent pulses, skin changes
- Neurogenic: variable distance, relief with sit/stoop, pain relieved by walking uphill, no pain with biking, pulses present, no skin changes
Spinal stenosis Tx
- NSAID’s (rarely narcotics)
- PT (water therapy)
- Epidural steroid injections
- Surgery
ACL Tear S/S
- Usually non-contact deceleration injury
- 1/3-1/2 report a pop w/immediate effusion
- Painful ROM and inability to bear weight
Lachman’s test
1) with knee in 15-20-degree flexion, one hand grasps femur
2) the other hand grasps tibia
3) Pull anteriorly
4) torn ACL will not have fixed end point
ACL Dx
- XR may show avulsion of tibial insertion
- MRI shows discontinuity of ligament
ACL Tx
- PRICE
- WBAT
- ROM
- Isometric exercises
- F/u in 10-14d
- Rehab
- surgery
Meniscus tear S/S
- Pain and instability with plant and pivot
- Intermittent s/s
- knee swells after clicking and buckling
Meniscus tear Dx
- McMurray’s test: pain, popping, or clicking
- XR: Well preserved joint space
- MRI: Posterior horn meniscus tear
Meniscus tear Tx
- PRICE
- NSAIDs
- Surgery
- Injection
MCL/LCL tears S/S
- knee forced into valgus or varus
- edema after injury
- pain with weight bearing
- unable to flex knee
MCL/LCL treatment
- PRICE
- APAP, tramadol, or NSAIDs
- PT
- Surgery (if other ligaments torn)
OA of knee S/S
- Common over 55yo
- Associated with obesity and family Hx
- S/S worse in AM and after inactivity
- Swelling in knees
- Sensation of buckling
- Stiffness and joint swelling
- limited ROM
OA of Knee Tx
- strength and motion exercises
- Glucosamine (1500mg/d for 6-8wk)
- Topical therapy
- APAP
- NSAID’s
- Tramadol
- Weight loss
OA of knee Tx (physical and injections)
- Cane on contralateral side
- joint aspiration/injection
- Surgery
Ankle sprain S/S
- Pain/swelling over lateral ankle structures
- loss of function
- report “pop”
Ottawa Rules for foot radiographs
- Tender posterior medial/lateral malleolus
- Tenderness medial or lateral midfoot
- Inability to bear weight
Ankle sprain Tx
- APAP, NSAIDs, tramadol
- PRICE (vigorous elevation [toes above nose])
- Cast or boot if severe
- WBAT, possible crutches
- ROM, stretching, strengthening and proprioception
- Stirrup splint 6wk
- PT for chronic instability
Fibromyalgia S/S
- Widespread MSK pain
- Tenderness at 11+/18 trigger points (joints spared)
- most common in women 20-55yo
- Sleep disturbance
- Joint stiffness
- Short-term memory loss
- Fatigue worse morning and evening
- Depression/anxiety
- Somatic complaints
Fibromyalgia Tx
- Education
- Muscle relaxants
- TCAs/SSRIs/SNRIs
- Short term NSAIDs/Tramadol/APAP
- Anticonvulsants (neurontin, lyrica)
- Steroids/ narcotics CONTRAINDICATED
RA S/S
- Usually symmetrical
- women >men; Peak onset 40-50s
- Gradual onset on symptoms
- Morning stiffness that improves through day
- synovitis of 3+ joints
- Rheumatic nodules
- Systemic: Malaise, fatigue, vasculitis, dry eyes, pericarditis
- Joint deformity
RA Dx
- RF factor
- ESR
- CRP
- CBC and ANA WNL
RA Tx
- refer to rheumatologist
- NSAIDs
- Steroids
- DMARDs
Gout S/S
- Abrupt severe pain of single joint
- Usually 1st MTP first joint effected (calor, edema, and erythema)
- Fever, chills
- Ankles, toe, and knee joints may become infected over time
- joint destruction may occur
Gout Tx
- NSAIDs (work best if initiated in 1st 24-hr)
- Colchicine (best if begun early)
- Steroid injections (if no active infection
- PO Steroids
- Prevention/Maintenance
- Allopurinol, Colchicine
