PD Musculoskeletal Flashcards
Function of MS system
Support and mobility
Protection
Hematopoeisis
Mineral storage
MS system
Bony structure with its joints held together by ligaments, attached to muscles by tendons, and cushioned by cartilage
Bones covered by…
Articular cartilage
What is the most common type of joint?
Diarthroidal (synovial)
Synovial membrane
Lines synovial cavity and secretes a small amount of viscous lubricating synovial fluid
What is surrounding synovial membrane?
Fibrous joint capsule
Strengthened by ligaments
Types of synovial joints
Spheroidal - ball and socket
Hinge
Condylar
Ball and socket examples
spheroidal
Shoulder
Hip
Hinge examples
Interphalangeal joints
Elbow
Condylar examples
Knee
TMJ
Bursa
Disc shaped, fluid filled synovial sacs that develop at points of friction around joints, between tendons, cartilage, and bone
Function of bursa
Decrease friction
Promote ease of motion
Examples of bursa
Subacromial Olecranon Trochanteric Pes anserine Prepatellar
Common, concerning symptoms
Low back pain Neck pain Muscular pain Limping Difficulty with gait Pain with movement Injury Joint pain
Examples of joint pain
Monarticular
Polyarticular
Associated with systemic symptoms
Historical clues
Functional limitation?
Sx with single joint/region or multiple joints?
Acute or slowly progressive?
Work hx, family hx?
Mechanism of injury?
Prior problems/injuries with the affected area?
Systemic symptoms
Examples of systemic symptoms
Fever, chills
Weight loss
GI issues
Skin issues
Exam
Inspection Palpation Range of motion Muscle strength Neuro vascular assessment Special maneuvers
Inspection
Anterior, posterior, and lateral aspects of posture
Symmetry of body parts, alignment of extremities
Lordosis, kyphosis, scoliosis
Skin over joints and muscles
Inspect muscles
Inspection of skin over joints
Discoloration - erythema, bruising, pallor
Swelling
Masses
Inspection of muscles
Hypertrophy
Atrophy
Fasciculations
Spasms
Palpation
Palpate all bones, joints, surrounding muscles
With palpation, note any…
Warmth TEnderness Swelling Fluctuation (joint effusion) Crepitus Muscle tone (spasticity, flaccid)
What areas do we palpate last?
Inflamed joints and tender areas last
ROM
Assess active and passive ROM for each major joint and related muscle groups, comparing side to side
Active ROM first, then relax and allow for passive ROM until end of ROM is felt
Do not force if there is pain or spasm
Which is greater, PROM or AROM?
PROM often greater than AROM by 5+ degrees
Signs that suggest problem with joint, related muscle group, or nerve injury
Pain Limitation of motion Spastic movt Joint instability Deformity Contractures
Goniometer
Used to precisely measure angle for range of motion
Part of neuro exam
Muscle strength
Neurovascular assessment
Sensory testing from neuro
Blood supply assessed with peripheral vascular exam
Most common complaint
Low back pain
Low back pain
Most cases are mechanical
Challenge to find pts with more serious disorders
Serious causes of low back pain
Malignancy (MM, mets) Infection Inflammatory disease Leaking aortic aneurysm Progressive neurologic deficits
Infection sources of low back pain
Discitis
Osteomyelitis
Epidural abscess
Malignancy sources of low back pain
Multiple myeloma
Mets
Inflammatory source of low back pain
Ankylosing spondylitis
History questions for LBP
Abrupt versus gradual onset Associated event (lifting, work, travel)
Character of LBP
Tearing, burning, steady ache
Tingling or numbness
Location/distribution of LBP
Sciatica typically radiates into buttock and down leg
Straight leg raise test
Tests for nerve root irritation or lumbar disk herniation at L4, L5, S1
Have pt lie supine with neck slightly flexed
Ask pt to raise leg
No pain should be felt below knee
Repeat on unaffected leg
Lasegue sign
Positive when patient is unable to raise leg greater than 30 degrees
Crossover pain in affected leg with straight leg raise test
Supportive of tension on nerve roots
Bragard stretch test
Tests for lumbar disk herniation at L4, L5, S1
Have pt lie supine with neck slightly flexed
Hold pts lower leg and raise it slowly with knee extended until pt feels pain
Lower leg slightly and briskly dorsiflex the foot
Pain will be produced if the nerve is inflamed
Femoral stretch test
Hip extension test that is used to detect inflammation of nerve root and L1 - sometimes L4 level
Patient lie prone and extend hip
No pain should be felt
Presence of pain on extension is positive sign of nerve root irritation
Common orthopedic shoulder DO
Rotator cuff tendonitis/bursitis/tear Adhesive capsulitis (frozen shoulder) Shoulder separation Shoulder dislocation Arthritis Labral tears Biceps tendonitis Instability Fractures
Elbow
Inspect in flexed and extended positions
Palpate bony prominences, olecranon bursa, muscles, tendons
Test muscle strength and ROM
Elbow ROM
Expect flexion of 160 and extension of 180
Pronation and supination of 90
Common elbow DO
Lateral epicondylitis Medial epicondylitis Bursitis (inflammatory, non, septic, olecranon) Arthritis Ulnar nerve entrapment Gouty tophi Rheumatoid nodules
Lateral/medial epicondylitis aka
Tennis elbow - lateral
Golfer’s elbow - medial
Hands and wrist
Inspect dorsal and palmar aspects Look for deformities of digits Palpate each joint in hand and wrist Palpate ulnar and radial arteries ROM Sensory and muscle strength
Palpation of hand and wrist
Swelling
Bogginess/effusions
Tenderness
Nodules
Tests for carpal tunnel
Tinel test
Phalen test
Rheumatoid arthritis
Chronic systemic inflammatory disease affecting mainly the synovial membranes of multiple joints
Symptoms of RA
Symmetric joint swelling and pain
Fatigue
Malaise
Early morning stiffness
PE with RA
Effusion Redness Tenderness in affected joints Subq nodules Late stages show characteristic deformities
Affected joints of RA
MCP
Wrist
Ankles
MTP
Swan neck deformitites
Hyperextension of PIP joint and flexion of DIP joint
Most commonly seen in RA
Boutounniere deformity
Flexion of PIP joint and hyperextension of DIP
Common in RA and trauma
Heberden’s nodes
Hard, contender nodules on DIP joints that occur slowly over time
Common in osteoarthritis
Bouchard’s nodes
Heberden’s nodes, but in PIP
Hard, contender nodules on PIP that occur slowly over time
Common in osteoarthritis
Ganglion cyst
Idiopathic, spontaneous protrusion of joint fluid outside of the articular surface
Painless, smooth, fluid filled cyst
Most commonly dorsum of wrist
Dupuytren’s contracture
Fixed flexion contracture that develops over time due to thickening of the palmar fascia
Rarely painful
Feels thick and tough on exam
De Quervain’s Tenosynovitis
Inflammation of tendon sheaths of extensor and abductor tendons of the thumb as the cross the styloid process
Perform Finkelstein’s test
Finkelstein’s test
Have pt put their thumb in the palm, covering it with other 4 digits, make a fist
Gently deviate wrist towards ulna, this stretches the inflamed tendons over the radial styloid, reproducing the patient’s pain
Carpal tunnel syndrome
Compression of median nerve by encroachment on the carpal tunnel
Causes of carpal tunnel syndrome
Fibrosis of tendon sheaths Trauma Arthritis Repetitive movements Pregnancy Past wrist injuries
S&S of carpal tunnel syndrome
Numbness and tingling progressing to weakness of first four fingers Pain in same distribution Anesthesia Weakness Thenar eminence atrophy
Tinel sign
Strike median nerve where it passes through the carpal tunnel (under flexor retinaculum and velar carpal ligaments)
Tingling sensation radiating from wrist to median nerve distribution is a positive Tinel sign
Phalen sign
Wrist is held in forced flexion for one minutes
Positive Phalen sign if patient develops paresthesias in nerve distribution
Paronychia
Tx
Painful bacterial (or fungal or viral) infection where skin and nail meet at the side or base of fingernail or toenail
Lancing to drain pus
Hip exam
Inspect hips anterioly and posteriorly while patient stands Locate major landmarks Asymmetry in height/alignment Level of gluteal folds Palpate hips and pelvis with pt supine ROM Leg length
Major landmarks
Iliac crest
ASIS
PSIS
Greater trochanter of femur
Abnormalities in palpation of hips and pelvis
Instability
Tenderness
Crepitus
Measuring leg length
Measure from ASIS to medial malleolus, crossing knee on medial side
Trendelenberg test
Maneuver to detect weak hip abductor muscles
Pt stands and balance first on one foot, then other
Observe from behind, note asymmetry or change in level of iliac crests
Trendelenberg test with iliac crest drop
When iliac crest drops on the side of lifted leg, hip abductors on weight bearing leg are weak
Trochanteric bursitis
S&S
Inflammation of trochanteric bursa which lies over the greater trochanter
Vague hip pain laterally, worse with walking and activity
Exam findings trochanteric bursitis
ROM preserved
Pain on direct palpation over bursa
Pain with resisted abduction
Osteoarthritis/degenerative joint disease
Pain with weight bearing and ambulation
Symptoms progress over time with pain precipitated by less activity as disease worsens
Mostly over 50 yo
Exam findings with OA
Pain with ambulation, often limping
ROM reduced as dz progresses
Early on internal rotation elicits the most pain
Knee exam
Inspect knees and popliteal spaces, both flexed and extended Note major landmarks Observe lower leg alignment Watch the pt walk Note scars, signs of swelling, inflammation Atrophy of muscles Palpate knee in all areas ROM Muscle strength Special test
Major landmarks
Tibila tuberosity Medial and lateral tibial condyles Medial and lateral epicondyles Adductor tubercle Patella
Normal lower leg alignment
Angle between femur and tibia is expected to be less than 15 degrees
Abnormal leg aligments
Valgus
Varus
Recurvatum
Valgus
Knock knees
Varus
Bowlegs
Recurvatum
Excessive hyperextension with weight bearing
Palpation of knee
Swelling Tenderness Crepitus Warmth Nodules
ROM of knee
Expect 130 flexion and 15 hyperextension
Palpating for joint effusion
Bulge sign
Ballotment
Balloon sign
Causes of joint effusion
Inflammation (infection, gout, RA)
Trauma, injury
DJD
Technique for smaller effusion
Bulge sign
Technique for large effusion
Ballotment
Balloon sign
Bulge sign
Knee extended, place left hand above knee and apply pressure on supra patellar pouch, displacing or milking fluid downward
Ballotment
Place left hand on supra patellar pouch
Gently push down towards patella, forcing any fluid to collect in central part of joint
Gently push down on patella with thumb
Patella will feel like its floating if a sizable effusion
Balloon sign
Place thumb and index finger of right hand on each side of patella
With left hand, compress supra patellar pouch against femur
Feel for clid entering spaces next to patella under right thumb and index finger
Special maneuvers
Abduction Valgus Stress Adduction Varus Stress Anterior drawer Lachman Posterior drawer McMurray Apley's
Test for MCL
Abduction Valgus stress test
Test for LCL
Adduction varus stress test
Test for ACL
Anterior drawer test
Lachman test
Test for PCL
Posterior drawer sign
Test for medial and lateral meniscus
McMurray test
Apley’s test
Valgus test
Tests MCL
Push medially on knee
Varus test
Tests LCL
Pull laterally on knee
Anterior drawer
Tests ACL
Lachman test
Tests ACL
Pulls knee out laterally while somewhat flexed
Posterior drawer
Tests PCL
McMurray’s test
Tests for tear of medial or lateral meniscus
Feeling of clicking or grinding under fingers
Apley’s test
Test for meniscal tears
Patient prone, knee flexed, hold foot pressing down and internally/externally rotate (bring)
Click, pops, snaps, indicate meniscal tear
Baker’s cyst
Common cause
Swelling in popliteal space caused by joint fluid protruding behind the knee
Common cause is DJD
Ankle and foot exam
Inspect feet and ankles while pt is weight bearing and sitting Observe contour of feet, alignment with tibia Position/size Number of toes Edema Ulcers Observe arch Palpate all labdmarks ROM Muscle strength Nuerovascular evaluation
Abnormal arches
Pes planus - flat foot
Pes cavus - high arch
Distal pulses
Palpate dorsalis pedis and posterior tibialis
Common sports injury
Ankle sprain
Grades of ankle sprain
I - III
Mild, moderate, severe
Grade I mild
Slight stretching and some damage to ligament
Grade II moderate
Partial tear with some joint laxity
Grade III severe
Complete tear with gross instability
85% of ankle sprains are…
Varus or inversion injuries
Resulting in lateral ligament complex tears
Lateral ligament tears
Anterior talofibular ligament (ATFL)
Calcaneofibular ligament (CFL)
Poseterior talofibular ligament (PTFL)
PE with ankle sprain
Ecchymoses
Swelling
Tenderness
Check anterior drawer
Plantar fascitits
Inflammation of the plantar fascia
Causes pain usually right at medial heel
Risk factors for plantar fasciitis
Poor foot mechanics Tight calf/Achilles Obesity/weight gain Improper footwear Pregnancy Running
Hammer toes
Toes crossed
Onychomycosis
Fungal infection of toenails (or fingernails)
