Musculoskeletal Assessment Flashcards
What are the 3 components of a Synovial joint
- Bones
- Synovial membrane
- Fibrous joint capsule
Who tends to have increased soft tissue laxity?
Younger people & women
= increased ROM (double-jointed)
How are fibrous joint capsules strengthened?
Strengthened by & in some cases continuous w/ ligaments extending from bone to bone
Bones are covered by what type of cartilage?
Covered by articulate cartilage (a collagen matrix containing charged ions/water that allows it to change shape in response to pressure or load
4 properties of Bones in the synovial joint
- do not touch
- joint articulation - freely movable w/in the limits of the surrounding ligaments
- covered by articulate cartilage
- separated by a synovial cavity that cushions joint movement
Synovial membrane in the joint?
Lines the synovial cavity
- secretes a small amount of viscous lubricating fluid called SYNOVIAL FLUID
What is the purpose of synovial fluid
Provides nutrition to the adjacent relative a vascular articulate cartilage
What determines the direction & extent of joint motion
The shape of the articulating surfaces of synovial joints
as well as:
surrounding soft tissues
What is a Bursae? And what does it do ?
Disc shaped synovial sacs
- facilitate joint action
- allow adjacent muscles or muscles & tendons to glide over each other during movement w/ reduced friction
Where is the bursae located?
Between the skin & the convex surface of a bone or joint (pre-patellar bursa of the knee)
- in areas where tendons or muscles rub against bone, ligaments, & each other (subacromial bursa of the shoulder)
What is a cartilaginous joint?
- fibrocartilaginous discs separate the bony surfaces
- fibrocartilage is compressible & shock absorber
What surrounds a cartilaginous joint?
Surfaces on either side of the joint are covered w/ Hyaline cartilage
What are 3 examples of Cartilaginous joints?
- Intervertebral joints
- Symphysis pubis
- Sternomanubrial joint
- Small amount of movement
What is a Fibrous Joint and what does it consist of?
The sutures of the skull
- have intervening layers of fibrous tissue or cartilage that hold the bones together
- almost in direct contact
- no appreciable movement
List the articular structures (4)
- The joint capsule & articular cartilage
- The synovial & synovial fluid
- Intro articular ligaments
- Juxtaarticular bone
What are the common pathologies seen in the articular structures? (4)
- Swelling & tenderness of the joint
- Crepitus
- Instability, “locking,” or deformity
- Limits ACTIVE & PASSIVE ROM due to stiffness, mechanical blockage or pain
Name the extra articular structures: (8)
- Periarticular ligaments
- Tendons
- Bursae
- Muscle
- Fascia
- Non-articular bone
- Nerves
- Overlying skin
What are common pathologies of extra-articular structures?
Typically involves point or focal tenderness in regions adjacent to articular structures
- Limits ACTIVE ROM only
- Rarely causes intra-articular joint swelling, instability, or joint deformity
What are the 3 common or concerning symptoms:
- Joint pain
- Neck pain
- Low back pain
When assessing joint pain, what do you need to determine?
- Whether the pain is articular or extra-articular
- Acute (usually days to weeks) vs. Chronic (usually months to years)
- Inflammatory or non-inflammatory
- Localized (mono articular) or diffuse (poly articular)
- Clarify: context, associations, & chronology
- Characterize the pain (“OLD CARTS”)
Pain in a single joint includes:
- Injury
- Monoarticular arthritis
- Extraarticular causes:
- tendinitis
- bursitis
- soft tissue injuries
Oligoarticular arthritis includes:
Infection:
- gonorrhea
- rheumatic fever
- connective tissue disease (Ether- Danlos)
- OA
Polyarthritis can be caused by:
Viral or inflammatory from:
- RA - Systemic Lupus erythmatosus (SLE) - Psoriasis
2 causes of smaller joint involvement
RA & SLE
What causes a migratory patter of pain spread?
Rheumatic Fever & Gonococcal arthritis
What causes an additive, progressive, symmetric pain pattern?
Rheumatoid arthritis
- gets worse over time
What are potential causes of ASYMMETRIC pain patterns?
- Psoriatic, Reactive, & Inflammatory bowel disease (IBD) - associated arthritis
Pain from the hip joint radiates where?
To the groin (poss. Knee pain)
Sacral/ Sacroiliac pain radiates where?
Buttock
Trochanteric pain radiates where?
Lateral thigh
Causes of inflammation:
- Infectious: Neisseria gonorrhea or Mycobacterium tuberculosis
- Crystal-induced: Gout, pseudogout
- Immune: RA & SLE
- Reactive: Rheumatic fever, reactive arthritis
- Idiopathic
How does activity affect inflammatory joint disorder?
Inflammatory = RA
- Rest tends to worsen the pain & activity improves pain
Morning stiffness that gradually improves w/ activity
How does activity affect mechanical joint disorders?
Mechanical = OA
- Activity increases the pain & stiffness & rest improves the pain
- Wax & Wayne = intermittent stiffness
- non-inflammatory = overuse (bursitis, tendinitis), degenerative changes (OA), or fibromyalgia
How does articular joint stiffness/pain affect ROM?
- Decreased active ROM (by the patient)
- Decreased passive (by the examiner) ROM with stiffness
How does periarticular joint pain affect ROM?
- Periarticular tenderness & pain w/ active ROM
- Passive ROM remains intact
True or False: Neck Pain often requires treatment?
False. Usually self-limited w/o the need for treatment
If your neck pain causes radiation, where does it normally radiate to?
The arm or scapular area
- Causes arm weakness, numbness, or parenthesis
Neck pain that causes radicular pain signals what?
Signals spinal nerve compression/irritation
- C6/C7 most common
What is the most common neck pain?
Degenerative joint changes (70%)
- compared to disc herniations (20-30%)(n. Compression)
What are the 3 categories of low back pain?
- Non-specific (>90%)
- musculoligamentous injuries & age-related degenerative processes of the intervertebral discs & facet joints
- Nerve root entrapment w/ radiculopathy or Spinal stenosis (~5%)
- Specific underlying disease (1%)
Back pain that is midline, over the spinous process includes:
- Musculoligamentous injury
- Disc herniations
- Degenerative disc disease
- Degenerative disease of the facet joints of the spine
- Vertebral fracture or collapse
- Spinal cord metastases or epidural abscess (rare)
Back pain that is off the midline, in the paraspinal muscles surrounding the spine include:
- Muscle strain
- Myofascial pain (trigger points)
- Sacroilitis
- Greater trochanteric pain syndrome
- Hip arthritis
- Renal conditions: pyelonephritis or stones
What is Sciatica?
Radicular gluteal & posterior leg pain usually caused by impingement nerve roots at the L4-S1 root levels
- Pain w/ forward flexion of the spine or straight leg raise or seated slump maneuvers
- or Valsalva or sneezing
Majority of Sciatica is assoc. w/ what?
85% of cases are assoc. w/ disc disorders usually L4-L5 or L5-S1 levels
How do you distinguish sciatic with spinal stenosis
Pain that improves w/ lumbar forward flexion is spinal stenosis
What can cause Cauda Equina Syndrome?
An S2-S4 midline disc herniations or tumors
What sign of Cauda Equina Syndrome is an emergency?
Bowel or Bladder dysfunction
- pursue immediate imaging & surgical evaluation
Inspection during a musculoskeletal exam should include:
- signs of deformity
- swelling
- scars
- inflammation
- muscle atrophy
Red flags for underlying systemic disease?
- age <20 or > 50
- Hx of cancer
- unexplained weight loss, fever, or decline in general hlth
- pain lasting > 1 mo or not responding to tx
- pain at night or present at rest
- Hx of intravenous drug use, addiction, or immunosuppression
- presence of active infection or HIV
- long-term steroid therapy
- Saddle anesthesia
- bladder or bowel incontinence
- neurological symptoms or progressive neurological deficit
- lower extremity weakness
Non-pharmacological Acute lower back pain treatment
- reassurance
- staying active
- heat
- massage
- acupuncture
- spinal manipulation therapy
Pharmacological Acute lower back pain treatment
- NSAIDs
- smooth muscle relaxants
Name the factors assoc. with poor outcomes of acute lower back pain
- maladaptive pain-coping behaviors: avoiding work, movement, or activities for fear of causing back damage
- multiple nonorganic physical examination findings
- psychiatric disorders
- poor general health
- high levels of baseline functional impairment
- low work satisfaction
Nonpharmacologic Chronic lower back pain treatment?
- all acute LBP tx’s
- back exercises
- multidisciplinary rehabilitation programs
- mindfulness-based stress reduction
- behavioral therapy
Pharmacological Chronic lower back pain treatment?
- all acute LBP tx’s
- Duloxetine (Cymbalta, SNRI) & tramadol
Where is the primary location of osteoporosis in those over 50 yo?
Femoral neck or lumbar spine
What is the prevalence of osteoporosis in race/ gender?
Mexican -American > Non-Hispanic white > non-Hispanic blacks
- Half of all post menopausal women sustain an osteoporosis related fx during their lifetime
- prevalence increases w/ age
What is osteoporosis? Osteopenia?
-porosis = weak & brittle bones
- penia = condition when the body doesn’t make new bone as quickly as it reabsorption old bone (lower than normal bone density)
- accounts for the majority of fragility fractures
Risk factors for Osteoporosis? (9)
- postmenopausal
- age > 50 yo
- prior fragility fx
- low body mass index
- low dietary calcium & Vit D deficiency
- tobacco & excessive alcohol use
- immobilization
- inadequate physical activity
- 1st degree relative w/ osteoporosis
Clinical conditions that increase the risk for osteoporosis ?
- thyrotoxicosis
- celiac Sprue
- IBD
- cirrhosis
- chronic renal disease
- organ transplantation
- diabetes
- HIV
- Hypogonadism
- multiple myeloma
- anorexia nervosa
- rheumatologic & autoimmune disorders
Medications that increase the risk factors for osteoporosis ?
- oral & high dose inhaled corticosteroids
- anticoagulants (long-term use)
- breast cancer
- methotrexate
- selected anti seizure medications
- immunosuppressive agents
- proton pump inhibitors (long-term use)
- androgen deprivation therapy for prostate cancer
What is the World Health Organization’s bone density criteria for osteoporosis?
T score < -2.5
> 2.5 standard deviations below the young adult mean
What is the World Health Organization’s bone density criteria for osteopenia?
T score between - 1.0 & - 2.5
(1. 0 to 2.5 standard deviations below the young adult mean)
- penia progresses to -porosis as T score becomes more negative
If you screen a patient for osteoporosis for fall risk and they say yes, what test should you do?
Do a gait, strength, & balance assessment with the TIMED GET UP & GO test
- high risk older adults that have a gait strength, or balance problem & at least 2 falls or at least one fall w/ an injury
Physical examination for the elderly at risk for falls include?
Assessment of:
- visual acuity
- postural dizziness/hypotension
- a cognitive screen
- inspection of the feet & use of footwear
- use of mobility aids
Follow up w/in 30 days
Your patient has received a neuraxial anesthetic technique what should you tell pack you?
Notify PACU about the block to alert that the patient is an Increased Fall Risk
- assess dermatomes if able
- S3 could poss. Ambulate
