Rheum/musculoskeletal Flashcards
Deposition of Monosodium urate crystals in joints
gout
Hyperuricemia
uric acid greater than 6.8. Treatment only indicated in those undergoing cytotoxic treatment.
Primary Overproducers
idiopathic, genetic
Secondary Over producers
increased purine consumption, malignancy, psoriasis, enzyme defects.
Primary underexcreters
idiopathic
secondary underexcreters
Most common. decreased renal function, metabolic acidosis, dehydration, meds, lead nephropathy.
Stage 1 gout
elevated uric acid levels with no symptoms.
Stage 2 gout
acute attack of arthritis
stage 3 gout
10 or more acute attacks. chronic swelling and tophi
Podagra
gout affecting the first MTP
Tophi
large aggregated crystals in the joint
Gout presentation
rapid onset, severe pain, redness, warmth and swelling. Usually monoarticular (big toe).
Gout triggers
ETOH, trauma, any medications that change uric acid levels, high purine consumption.
Xray of gout
Joint erosion. “rat bite”
Arthrocentesis of gout
gold standard. needle shaped and NEGATIVE birefringent crystals
24 urine uric acid
overproducers with have more than 800mg on a normal diet.
Acute Gout Attack Treatment
1st line: NSAIDS, indomethacin 50mg TID or naproxen 500mg BID
2nd line: colchicine 1.2mg followed by 0.6mg an hour later then 0.6mg BID.
3rd line: Glucocorticoids
Gout prevention
avoid high purine foods, prophylactic treatment and urate lowering therapy.
Chronic gout treatment indications
frequent attacks, polyarticular, tophi, renal stones.
Gout treatment goals
SUA of 6.0mg or less.
Probenecid
Gout. For underexcreters. Enhances renal excretion. 250mg BID. Avoid with nephrolithiasis and aspirin.
Allopurinol (Xanthine oxidase inhibitor)
Agent of choice for gout. Decreases uric acid synthesis. 300mg a day. renal dosing.
Febuxostat (xanthine oxidase inhibitor)
similar to allopurinol. safe with mild-moderate renal insufficiency.
Chronic gout treatment
urate lowering therapy should be started 2 weeks after an acute attack. need to have prohpylaxis of NSAIDS/colchicine before starting.
Calcium pyrophosphate dihydrate depostion disease
Pseudogout
chondrocalcinosis
radiographic evidence of calcification. punctate and linear.
psuedogout presentation
acute, monoarticular inflammatory arthritis. usually effects the knees, wrists or shoulder.
Pseudogout arthrocentesis
POSITIVELY birefringent. rhomboid shaped CPPD crystals.
Psuedogout acute treatment
NSAIDS, colchicine, glucocorticoids. Joint aspiration. intrarticular glucocorticoids. immobilization and ice.
Pseudogout prophylaxis
if greater than 3 attacks per year. Cochicine 0.6mg BID
Systemic Lupus Erythematosus (SLE) Etiology
Autoimmune disorder with autoantibodies to nuclear antigens. Genes, environment, hormones.
SLE pathogenesis
ANA then antibody/antigen complexes then deposit in tissues which activate complement causing inflammation.
SLE presentation
Fever, Fatigue, weight change, photosensitivity, alopecia, malar/discoid rash, arthritis, serositis, lupus nephritis, seizures, Raynaods phenomenon, peritonitis, vasculitis, ophthalmologic involvement, recurrent fetal loss.
SLE Diagnosis
ANA is cardinal feature but is not specific. immunofluorecence shows anti-dsDNA and anti-sm antibodies.
SLE treatment
Step wise approach. NSAIDS. Antimalarials (hydroxychloroquine with ophthalmologic follow up). systemic corticosteroids. cytotoxic/immunosuppressive agents (methotrexate, azathioprine). Belimumab (monoclonal antibody).
Drug induced SLE
Constitutional symptoms, pleuropericardial symptoms. Positive antihistone antibody.
Drug induced SLE treatment
stop the offending drug
Sjogren Syndrome etiology
Chronic, autoimmune. Diminished exocrine gland function.
Sicca complex
dry eyes and mouth
sjogren syndrome presentation
fatigue, keratoconjunctivitis (dry eyes), xerostoma, parotid gland enlargement, mucous membrane dryness, arthritis, Raynaud’s, lymphadenopathy, pulomary disease, vasculitis, nephritis, lymphoma.
Raynaud’s phenomenon
episodic vasospastic disease. white then blue then red fingers.
Sjogren syndrome diagnosis
ANA. Anti-Ro/ssa and anti-La/ssB. elevated RF.
Sjogren syndrome treatment
Dentist and optomotrist follow up. cyclosporine eye drops (restasis), biotene. Steroids/immunosuppressants.
Systemic sclerosis (scleroderma) etiology
Rare, chronic autoimmune disorder causing diffuse fibrosis of skin and organs.
Systemic sclerosis pathogenesis
immunologic mechanisms lead to vascular endothelial damage and activation of fibroblasts.
Systemic sclerosis presentation
arthritis, pulmonary fibrosis, pericarditis, renal failure, cutaneous symptoms.
Limited cutaneous systemic sclerosis
CREST. Calcinosis cutis, Raynaud’s, Esophageal dysmotility, Sclerodactyly (puffy hands), Telengiectasia.
Diffuse cutaneous Systemic sclerosis
rapid symmetric skin thickening of trunk and proximal extremities.
Systemic Sclerosis Diagnosis
ANA. anti-SCL-70 and anti-centromere antibodies.
Systemic Sclerosis Treatment
Supportive. Raynauds: nifedipine. Esophageal dysmotility: H2 blockers. HTN: ace inhibitors.
Reactive Arthritis etiology
inflammatory arthritis triggered by a GI/GU infection (diarrhea or urethritis). shigella, salmonella, yersinis and campylobacter. chlamydia.
Reactive Arthritis Presentation
asymmetric oligoarthritis (can’t climb a tree), conjunctivits (can’t see), urethritis (can’t pee). ulcers, keratoderma blennorrhagicum (hyperpigmentation of soles/palms), circinate balanitis (on penis), nail changes.
Reactive Arthritis Diagnosis
HLA-B27 antigen. Synovial fluid: inflammation but non infection.
Reactive arthritis treatment
NSAIDS: indomethacine 25-50mg TID.
Rhuematoid Arthritis (RA) etiology
autoimmune, chronic, inflammatory disorder.
RA pathogenesis
Interluekins effect the T cells, increasing TNF, leading to inflammation and osteoclastogenesis causing bone erosion.
RA Presentation
symmetric polyarthritis. Morning sitffness >1 hour. Pain, swelling, MCP and DIP joints. Ulnar deviation. Boutonniere, swan-neck, interosseous hypertrophy. Adhesive capsulitis, baker’s cyst, metatarsal head subluxation.
RA Extraarticular manifestations
constitutional symptoms, rheumatoid nodules, episceleritis/scleritis, pericarditis, plueritis, sicca, hematologic. Cardiovascular disease is most common cause of death.
Felty Syndrome
RA, Splenomegaly, neutropenia.
RA radiology
soft-tissue swelling, osteopenia, narrowing of the joint, subluxation, bone erosion/joint obliteration.
RA Labs
Rheumatoid Factor. Anti-CCP, ANA (30%). Inflammatory markers (ESR and CRP).
RA Treatment
Exercise with rest periods. NSAIDS, glucocorticoids, Disease Modifying Antirhuematic Drugs (DMARD)
Synthetic DMARDs
Methotrexate, sulfasalazine, hydroxycholoraquine.
Biological DMARDs
Inhibit inflammatory cytokines (TNF-alpha). High risk of infection, myelosuppression and malignancy. Etanercept (enbrel), Infliximab (remicaid), Adalmumab (humira).
Osteoarthritis (OA) Pathogenesis
damage leads to chondrocytes then degradative enzyems causing thinning of articular cartilage and bone remodeling (bone spurs and joint space narrowing).
OA Symptoms
pain that is exacerbated by activity and relieved by rest. Morning stiffness that last for less than 30 minutes.
OA General Signs
crepitus, bony enlargements, decreased ROM, malalignment, tenderness.
OA of the hands
Heberden’s nodes ( DIP), bouchard’s nodes (PIP), oftern in first CMC joint.
OA of the knees
Osteophytes, effusions, crepitus, decreased ROM.
OA of the hip
decreased internal rotation, pain in hip/groin, pain that radiates to the knee.
OA radiology
joint narrowing, osteophytes, subchondral sclerosis, subchondral cysts.
OA Treatment
Weight loss, PT, tylenol, NSAIDS, narcotics (sparingly), topical NSIADS (diclofenac or capsaicin), intraarticular glucocorticoids or hyaluronic acid.
Polymyalgia Rheumatica Etiology
Chronic, inflammatory rhuematic condition associated with giant cell temporal arteritis. women > 50 years old.
Polymyalgia presentation
morning stiffness, symmetric, shoulder>hip/neck pain, synovitis/bursitis, edema, decreased ROM, subjective weakness, systemic symptoms.
Polymyalgia Labs
elevated ESR > 40.
Polymyalgia diagnosis
Proximal bilateral aching with morning stiffness for > 30 mins for > 2 weeks. Rapid resolution with low-dose glucocorticoids.
Polymyalgia Treatment
NSAIDS, PT, glucocorticoids (15-20mg/day).
Fibromyalgia etiology
idiopathic. Soft tissue pain disorder with widespread, chronic pain. No inflammaiton.
Fibromyalgia presentation
aching, stiffness, paresthesias, HA, fatigue, mood disturbances (anxiety and depression), disturbed sleep, pelvic pain, IBS, painful bladder syndrome.
Fibromyalgia diagnosis
All labs are negative. Symptoms of widespread pain that is above/below the waist and on right/left sides of the body with at least 11/18 tender spots.
Fibromyalgia Treatment
NSAIDS, Cyclobenzapine (muscle relaxer), antidepresants (amitriptyline, duloxetine, milnacipran), anticonvulsants (pregabalin, gabapentin). Avoid narcotics.
Rotator Cuff Muscles in order
Supraspinatus, infraspinatus, teres minor (external rotation and abduction), subscapularis (internal rotation).
Most common rotator cuff tear
supraspinatus
General Rotator Cuff symptoms
Pain over anterior/lateral shoulder. Radiates to deltoid. Occurs with overhead activities. Decreased abduction.
Rotator Cuff tests
drop arm (complete tear), empty can, neer’s, hawkins.
Tendinosis
Degeneration of muscles typically due to age
Tendonitis
Inflammation due to repetitive trauma
Chronic rotator cuff tear causes
Degeneration, impingement and overload. Overhead occupations. Anatomical variations that cause narrowing. Men >40.
Acute rotator cuff tear causes
Traums. acute pain with negative radiographs. Labral pathology.
Chronic rotator cuff symptoms
Pain worse at night. gradual weakness. Does NOT improve with analgesics. positive drop arm and empty can tests.
Rotator cuff radiography
elevation of humeral head suggests tear.
MRI of rotator cuff
if full thickness is suspected of labral pathology.
Acute Rotator cuff tear treatment
Ice, NSAIDs, weighted pendulum stretch BID, restrict overhead movement, immobilization for a short time, PT after initial rest.
Chronic Rotator Cuff tear treatment
subacromial steroid injection (3-4 times per year). Surgery either arthroscopic or joint arthroplasty.
Shoulder impingement Syndrome Presentation
subacromial tenderness, normal ROM but pain at >90 degrees. Deep ache. Preserved strength. Pain with flexion and internal rotation. Positive neer’s and hawkins tests. Improves with analgesics.
Shoulder impingement syndrome treatment
Ice, NSAIDs, activity modification, PT. Steroid injections if persistent. Surgery if anatomical variation can be fixed.
Adhesive capsulitis etiology
trauma, overuse, bursitis, sling use.
Adhesive capsulitis Presentation
chronic pain, decreased ROM due to mechanical restirction. usually effects abduction and external rotation. positive apley’s scratch test.
Adhesive capsulitis treatment
PT
Acromioclavicular Injury MOI
fall onto the tip of the shoulder with the arm tucked into the side.
Acromioclavicular Injury Presentation
AC joint swelling/deformity/tenderness. Pain worse at bedtime. Pain worse with downward traction and cross-over test.
AC injury grade I
Sprain. Radiographs are normal.
AC injury Grade II
speration of the superior/inferior AC ligaments. Instability, decreased ROM. Radiograph shows inferior margin of clavicle lies above the inferior margin of the acromion.
AC injury Grade III
Seperation of superior/inferior AC and coracoclavicular ligament. Clinical deformity. Severe pain. Radiograph shoes the inferior margin of the clavicle above the superior margin or the acromion.
AC injury treatment
Ice, rest, NSAIDs, shoulder immobilizer (3-4 weeks), corticosteroid injection .
AC injury surgery
Grade III with fixation, ligament reconstruction and distal clavicle resection.
Typical Clavicle fracture
occurs in the middle and displaces superiorly.
Clavicle fracture presentation
visual deformity, tenderness, decreased ROM with apprehension.
Clavicle fracture treatment
sling/swathe or figure 8 harness. analgesics, muscle relaxers.
Clavicle fracture ortho referral if…
displaced mid clavicle and all proximal/distal fractures.
Subacromial bursitis etiology
inflammation or degeneration of the bursa due to repetitive movement or a systemic disease. Can be associated with rotator cuff tendonitis/impingement.
Subacromial bursitis presentation
pain with ROM and at rest. localized tenderness of subacromial area.
Subacromial bursitis treatment
ice, NSAIDs, rest, aspiration and corticosteriod injections
Carpal Tunnel syndrome (CTS) pathogenesis
Repetitive activities that cause swelling of the synovium and thickening of the transverse carpal ligament.
CTS presentation
Chronic intermittent pain (dull ache) leading to burning pain, numbness, tingling and weakness. worse at night.
CTS Tests
Phalens and tinels
CTS signs
Thenar atrophy, decreased sensory and and strength in median nerve distribution.
CTS Diagnostics
Grip strength test, nerve conduction tests, electromyogram.
CTS Treatement
NSAIDs, steroid injuections, brace, PT, surger.
Acute CTS treatment
Immediate decompression.
Ganglion cysts Etiology
collection of synovial fluid within a joint or tendon sheath.
Ganglion cyst presentation
dorsal/volar aspect of wrist. Soft mobile mass that fluctuates in size.
Ganglion cyst treatment
NSAIDs, aspiration with steroid injection. Often resolve on their own.
De Quervain’s tendosynovitis etiology
Inflammation of the first dorsal compartment involving abductor pollicis longus and extensor pollicis brevi due to overuse (repetitive gripping).
De Q’s Presentation
pain/swelling along dorsal wrist. positive finkelstein’s test. Pain aggravated by gripping.
De Q’s Treatment
rest, thumb spica immobilization, NSAIDs, steroid injections.
Boutonniere deformity
PIP flexion, DIP hyperextension.
Swan neck deformity
PIP Hyperextension, DIP flexion.
Biceps tendonitis etiology
Inflammation of the long head of the bicep as it passes through the bicepetal groove. Due to repetitive lifting.
Biceps tendonitis presentation
pain in anterior shoulder (bicipetal groove), pain with abduction and external rotation, popping, weakness.
Biceps tendonitis tests
Yergason’s and speeds.
Biceps tendonitis treatment
NSAIDs, rest, PT to strengthen the bicep.
Glenohumeral dislocation/subluxation Presentation
Sulcus sign, usually dislocates anteriorly, apprehension/relocation test.
Multi-axial instability treatment
PT, analgesics, ice and rest.
Glenohumeral dislocation treatment
immediate reducation, should immobilizer (2-4 weeks), analgesics, PT. Consider axillary nerve damage (numbness over deltoid).
Bankart lesion
detachment of anterior/inferior labrum from glenoid rim
Hills-Sachs lesion
cortical depression of posterolateral humeral head.
Elbow epicondylitis etiology
over use.
Elbow epicondylitis presentation
localized pain/swelling. Reproducible pain with wrist flexion (medial) or wrist extension (lateral).
Medial elbow epicondylitis
golfer’s elbow. Wrist flexors and protonators.
Lateral elbow epicondylitis
tennis elbow. wrist extensors and supinators.
Elbow epicondylitis acute treatment
sling, wrist brace, ice, NSAIDs.
Elbow epicondylitis prevention
forearm strap, correct technique, minimize repetitive injury.
Elbow epicondylitis chronic treatment
steroid injections and surgery.
Olecranon bursitis etiology
trauma, prolonged pressure, infection, rhematological conditions.
Olecranon bursitis presentation
swelling, +/- pain, +/- decreased ROM
Olecranon bursitis treatment
Ice, NSAIDs, aspiration.
Olecranon bursitis Prevention
elbow pads, change activity.
Cubital tunnel Etiology
Compression of the ulnar nerve due to repetitive motion, pressure, fluid or trauma.
Cubital tunnel presentation
ulnar nerve neuropathy, decreased grip strength, muscle wasting.
Cubital tunnel treatment
NSAIDS, bracing, PT, surgery (cubital tunnel release or ulnar nerve transposition).
Dupuytren’s contracture etiology
connective tissue disorder. progressive fibrosis of the palmar fascia.
Dup’s contracture presentation
painless nodules that become palpable cords along the palmer surface. Loss of finger extension.
Dup’s contracture Test
hueston table top test
Dup’s contracture treatment
stretching, splinting, massage, glucocorticoid injections, surger if contracture is >30 degrees.
Trigger thumb/finger etiology
nodule on volar aspect of the MCP
Trigger thumb/finger presentation
digit snaps/catches at IP or PIP joint. Becomes painful.
Trigger thumb/finger treatment
NSAIDs, steroid injections, surgery to release the A1 pulley.
Strain
muscle/tendon injury
Sprain
ligamentous injury
Radiculopathy
Lower motor neuron dysfunction. Dermatomal distribution. hypoactive reflexes. Flaccidity. Fasciculations.
Myelopathy
Upper motor neuron dysfunction. Hyperactive reflexes. clonus. upgoing toes (babinski). spasticity.
C5 Sensory
Lateral/upper arm and shoulder.
C5 Motor
deltoid and some bicep (abduction)
C5 DTR
Biceps or brachioradialis
C6 sensory
dorsolateral arm, forearm and thumb
C6 motor
biceps, brachioradialis and wrist extensors.
C6 DTR
biceps or brachioradialis
C7 sensory
mid-dorsal forearm and middle finger.
C7 Motor
triceps, wrist flexors and finger extensors.
C7 DTR
Triceps
C8 sensory
medial forearm, ring finger, small finger.
C8 motor
thenar eminence and interossei.
L3 sensory
anterior thigh
L3 motor
iliopsoas.
L3 DTR
knee jerk
L4 sensory
anteromedial thigh and medial leg.
L4 motor
quads
L4 DTR
knee jerk
L5 sensory
lateral thigh and anterior calf.
L5 motor
foot dorsiflexion, anterior tibialis and extensor hallucis longus.
S1 sensory
Posterior calf and heel.
S1 motor
gastrocnemius.
S1 DTR
achilles
X-ray films indications
trauma, degenerative diseases.
CT indications
bony detail
MRI indications
soft tissue structures and neural compression
Bone scan indications
infectious or metastatic diseases
Electromyogram (EMG)
differentiates root vs. peripheral vs. plexus problem
Nerve conduction study
problem with the axon vs. myelin. determines the amplitude and speed of response.
Cervical sprain etiology
rapid deceleration injury that causes hyperextension then flexion. inflammatory response that presents 2-24 hours after trauma.
Cervical Sprain Presentation
gradual onset of stiffness/soreness. HA at base of skull. shoulder pain.
Lumbar Sprain etiology
lifting and twisting
Lumbar sprain presentation
worsens with activity and resolves with rest. radiates to the buttocks. common to have reoccuring episodes.
Signs of spinal strains/sprains
tenderness, decreased ROM due to pain, muscle spasms.
Spinal strain/sprain imaging
plain films
Spinal strain/sprain treatment
Rest (no more than 48 hours), RICE, NSAIDS (for 72 hours not PRN), PT, usually resolves withing 4 weeks.
Herniated lumbar disk etiology
Repetitive movements or acute injury usually L4/5 or L5/S1 posterolateral. Often associated with lumbar strain.
Herniated Lumbar disk Presentation
Pain radiating down the back of the legs. Aggravated by coughing/sneezing. Hard to get comfortable. Trunk shifted to one side for compensation.
Herniated Lumbar disk Diagnostics
Straight leg raise test (gold standard). MRI.
Herniated Lumbar disk treatment
Best rest (1-2 days), NSAIDs, muscle relaxants (cyclobenzaprine), heat or ice, PT. Urgent referral for any neuro deficits. Surgery if intractable or neuro deficits.
Cervical Spondylosis etiology
degenerative disk disease and hypertropy of ligamentum flavum and facets.
Cervical Spondylosis Presentation
unilateral radicular symptoms or bilateral myelopathy. tenderness, muscle spasms.
Cervical spondylosis treatment
Best rest (1-2 days), NSAIDs, muscle relaxants (cyclobenzaprine), heat or ice, PT. Urgent referral for any neuro deficits. Surgery if intractable or neuro deficits.
Cauda Equina Syndrome etiology
Massive midline herniation. Neuro Emergency.
Cauda Equina Presentation
acute onset of low back pain, sciatica, urinary retention, decreased anal sphincter tone, “saddle” anesthesia.
Cauda Equina Imaging
MRI
Cauda equina treatment
urgent surgical decompression or oncology referral for metastatic disease.
Spondylolysis
Defect in the pars interarticularis (collar on the scottie dog) due to repetitive hyperextension of the back. common in adolescents. treated with NSAIDs and rest.
Spondylolisthesis etiology
degenerative disk disease causing anterior displacement of one vertebra on another.
Spondylolisthesis Presentation
back pain that is aggravated by lifting/twisting. Can have step offs.
Spondylolisthesis treatment
50% or neuro deficits: Refer to ortho or neuro.
Lumbar spinal stenosis etiology
congentical or degenerative disk disease with hypertrophy of the ligamentum flavum causing narrowing of the neural foramen creating compression.
Nerogenic claudication
Seen with lumbar stenosis. progressive low back pain and bilateral leg pain aggravated by standing/walking and relieved by leaning forward.
Lumbar stenosis treatment
conservative treatment, epidural steroid injections. Surgery if intractable or neuro deficits.
osteomyelitis
infection usually associated with invasive procedues. back pain, malaise, fever, sepsis, wound drainage, elevated EST. Treated with IV antibiotics and surgical drainage.
Spinal tumors (secondary)
90%. New onset of low back pain with known malignancy is metastasis until proven otherwise.
Femoroacetabular Impingement (FAI) etiology
Progressive bone overgrowth or abnormality that changes the function of the hip. Can lead to labral tears and OA.
FAI Pincer
acetabular involvement
FAI Cam
Femoral head involvement
FAI Presntation
groin and/or lateral hip pain. Sharp throbbing to dull achy. Aggravated with turning/twisting/standing/squatting.
FAI test
Impingement Test. FADIT and FABER
FADIR test
flexion, adduction then internal rotation
FABIR test
figure of four. flexion abduction then external rotation.
FAI treatment
decrease aggravation, conservative therapy, surgery if that doesn’t work
Labral Tear of the hip presentation
dull to sharp groin pain that can radiate to the lateral hip, anterior thigh and/or buttock. catching/clicking.
Labral tear of hip Diagnositcs
ROM, strength, FADIR and FABER. MR anthrogram is gold standard.
Labral Tear of hip treatment
conservative then refer.
Snapping hip syndorme etiology
muscle/tendon sliding over a bony prominence. Can lead to bursitis.
Snapping hip external
IT band over greater trochanter.
Snapping hip internal
Iliopsoas tendon over the iliopectineal eminence of the femoral head.
Snapping hip presentation
snapping/popping sensation, +/- pain, aggravated with activity, pseudosubluxation, difficulty with stairs, rising from seated position.
External snapping hip tests
Passive internal/external rotation while on side.
Internal snapping hip tests
FABER then extending the hip.
Snapping hip treatment
Conservative treatment, steroid injection, PT.
Greater Trochanteric Pain syndrome etiology
Most common cause of lateral hip pain. Due to repetitive overload tendinopathy leading to an inflammed bursa.
Greater Troch pain Presentation
Lateral hip pain, pinpoint tenderness on greater trochanter, pain with activity.
Greater troch pain tests
pain with resisted abduction. Trendelenburg sign.
Trendelenburg sign
Can’t stabilize the pelvis. The contralateral side dips due to weak pelvic stabilizers.
MCL MOI
knee flexed, foot planted with a lateral impact that causes valgus stress and rotation.
Triad of O’Donoghue
ACl, MCL, and medial meniscus.
ACL MOI
quick position change with valgus stress (pivoting/cutting). or a direct blow that causes hyperextension and valgus stress.
ACL function
Most important for knee stability. prevents posterior movement or the tibia as well as rotation.
ACL Presentation
“pop” followed by immediate swelling/pain. Feeling of instability. Joint effusion, guarding, usually able to bear weight, laxity.
ACL tests
Lachman, anterior drawer test and pivot shift. MRI.
ACL Treatment
Conservative. Surgery for younger people and athletes.
PCL function
Prevents posterior movement of the tibia and external rotation.
PCL MOI
high energy trauma (MVA), low energy trauma (soccer).
PCL presentation
gross instability, mild-moderate effusion, generalized knee pain.
PCL tests
posterior drawer test and posterior sag sign.
Meniscus injury MOI
Usually medial meniscus. Occurs due to excessive rotational force.
Meniscus injury presentation
joint line pain, inability to fully extend knee, locking/catching, difficulty with stairs and squatting.
meniscus injury tests
mcmurray’s, apley’s compression/distraction. MRI.
Knee sprain Grade I treatment
mild stretch. Conservative treatment.
Knee sprain Grade II treatment
partial tear. RICE, brace, crutches, PT, possible surgery.
Knee sprain grade III treatment
full tear. surgery, crutches, brace, aggressive PT.
Patellofemoral pain syndrome etiology
Malalignment and patellar tracking concerns. Most common knee complaint.
Patellofemoral pain presentation
pain behind the patella, worse with stairs, and after sitting for a long time. crepitus, popping, feeling of unstable.
patellofemoral pain tests
patellar glide and apprehension test.
patellofemoral pain treatment
conservative. PT. brace PRN for comfort.
Baker’s cyst etiology
accumulation of synovial fluid in the popliteal fossa.
Baker’s cyst presentation
oftern asymptomatic. pain/swelling with prolonged activity.
Baker’s cyst treatment
NSAIDS, aspiration/injection, compressive knee brace.
Patellar tendonitis etiology
tendon inflammation due to repetitive trauma often from jumping.
Patellar tendonitis treatment
Conservative. NO steroid injection.
patellar tendonitis presnentation
pinpoint tenderness just inferior to the patella.
Iliotibial band syndrome (ITBS) etiology
overuse syndrome usually in runners.
ITBS presentation
gradual onset of localized pain and tenderness. reproducible pain with ROM and compression of the ITB. Evaluate for any leg length discrepancies.
ITBS treatment
Conservative.
Knee bursitis etiology
inflammatory disorder of the bursa usually prepatellar or pes anserine. Caused by trauma or overuse.
Knee bursitis presentation
pain/swelling, tenderness. Need to rule out infection.
Knee bursitis treatment
NSAIDS, aspiration/injection, padding/brace.
Osteochondritis Dissecans (OCD) etiology
lesion of cartilage and underlying bone that results in necrosis and possible displacement.
OCD treatment
long-term bracing, activity restrictions, PT.
Lateral ankle sprain MOI
inversion with plantar flexion
Lateral ankle sprain tests
anterior drawer test.
Lateral ligament complex
anterior talofibular, calcaneofibular, and posterior talofibular ligaments.
Medial ankle sprain
eversion injury. deltoid ligament complex.
Syndesmotic sprain
high ankle sprain. Due to dorsiflexion +/- rotation.
Achilles tendinopathy
recent incrase in training regimen, burning pain with activity.
Achilles rupture MOI
sudden pivoting or rapid acceleration. violent pop, often pain is absent.
Achilles injury test
Thompson test.
Achilles injury treatment
refer to ortho. equinos splint with continuous plantar flexion.
Plantar fasciitis etiology
inflammation of the fascia due to activity, heel spurs, pes planus/cavus, ankle pronaiton, poor shoe wear.
Plantar fasciitis presentation
Pain on plantar aspect of heel. Pain with onset of walking in the morning. uni or bilateral. aggravated with dorsiflexion.
Plantar fasciitis treatment
conservative. PT and massage.
Osteoporosis treatment
Calcium supplements, estrogen replacement, calcitonin and bisphosphonates.
Septic arthritis presentation
increasing pain, redness, warmth, inflammation. surgical emergency.
septic arthritis diagnosis
aspiration with culture. CBC, EST, CRP, blood cultures.
septic arthritis treatment
IV antibiotics and I/D
Unicameral Bone Cyst
common, benign fluid filled cavity in the bone. Surgery if recurrent or pathological fractures.
Aneurysmal bone cyst
blood filled cyst in the bone. benign but aggressive. refer to ortho.
Non-ossifying fibroma
benign lesion usually found incidentally. MES: metaphysial, eccentric, sclerotic borders. Observe and refer is >50% of diameter.
Giant Cell tumor
benign but aggressive. develop as the growth plate closes. localized pain and weakness. refer to ortho for radiation and surgery.
Osteoid Osteoma
small, benign tumor. Nidus: center of growing cells surrounded by thick bone. severe night time pain that is resolved with NSAIDS. Refer to ortho.
Osteochondroma
exostosis. abnormal growth of bone or cartilage along the bone surface. Most common and bengin tumor. Fixed, non-mobile mass near joints. Some pain with activity. If painful refer to ortho.
Osteosarcome/ewings sarcoma
malignant primary bone tumor common in children. Can be aymptomatic until pathological fracture. pain/swelling. Refer to ortho/onc immediately. Fast growing.
Chondrosarcoma
Bone tumor composed of cartilage-producing cells. >40 years of age. pain and weakness. refer to ortho.
Multiple myeloma
most common primary bone tumor. > 40 years of age, black people. Involves the entire skeleton.
Multiple myeloma presentation
fatigue, fever, night sweats, diffuse bone tenderness, pathological fractures.
Multiple myeloma diagnosis
UA with bence jones proteins. radiograph that shows punched out appearance.
Most common cause of metastatic bone cancer in men
prostate and lung
most common cause of metatstatic bone cancer in women
breast.
Causes of metastatic bone cancer
prostate, lung, breast, kidney and thyroid cancer.
Metastatic bone cancer presentation
asymptomatic until pathological fracture. anemia. osteolytic bone destruction and osteoblastic formation.
