UW 2 Flashcards
Overview of running injuries of the foot and ankle - ddx
- stress fracture
- plantar fascitis
- achilles tendinopathy
- motor neuroma
- tarsal tunnel syndrome
stress fracture - RF
- repetitive activities (running, gymnastics)
- abrupt increase in physical activity
- inadequate calcium + vit D intake
- decreased caloric intake
- female athelte triad: low caloric, hypomenorrhea/amenorrhea, low bone density
stress fracture - presentation
insidious onset of localized pain
point tenderness at fracture site
possible negative x-ray in the first 6 wks
stress fracture - x-ray
possible negative for the 1st 6 wks
stress fracture - management
reduced weight bearing for 4-6 wks
referral to orthopedic surgeon for fracture at high risk for maluntion (anterior tibial cortex, 5th metatarsal)
medial tibial stress syndrome (shin splints)
anteror leg pain resembling that of stress fractrure –> usually seen in casual runners and is characterized by diffuse area of tnederness (not point tenderness vs stress fracture) –> common in overweight (vs stress
when to treat a stress fracture with casting or internal fixation
if increased risk for nonunion: 5th metatarsal or anterior tibial cortex
MC metatarsal with stress fracture
2nd
shin splints vs stress fracture
shin: obesity, no tender
fracture: low BMI, tender
plantar fascitis - definition
inflammation of plantar aponeurosis characterized by eel pain (worse with first step in the morning or after period of inactivity) and tenderness
achilles tnedinopathy - clinical features
burning pain or stifness 2-6 cm above the posterior calcaneus
motor neuroma - clinical features
- numbness or pain between the 3rd and 4th toes
- clicking sensation when palating space between 3rd and 4th toes while squeezing the metatarsal joints (Mulder’s sign)
tarsal tunnel syndrome - clinical features
- compression of the tibial nerve at the ankle
- burning, numbness + aching of the distal plantar surface of the foot/toes
common causes of shoulder pain
- Rotator cuff impingement or tendinopathy
- rotator cuff tear
- Adhesive capsulitis (frozen shoulder)
- Biceps tenindopathy rupture
- Gienohumeral osteoarthritis
Rotator cuff impingement or tendinopathy
- pain with abduction, external rotation
subacrosomial tenderness - normal range of motion with positive impigement tests
- NEAR TEST: with the patient’s shoulder internally roated and forearm pronated, the examiner stabilizes the scapula and flexes the humerus -> reproduction of the pain
Rotator cuff tear
similar to rotator cuff tendinopathy
- weakness with abduction + external rotation
- older than 40
- usually after a fall on an outstrected ar
adhensive capsulitis (frozen shoulder)
decreaed passive + active range of motion
more stiffness than pain
FIBROSIS
biceps tendinoapthy / rupture
anterior shoulder pain
pain with lifting carrying or overhead reaching
weakness less common
glenohumeral osteoarthritis
uncommon + usually due to trauma
gradual onset of anterior or deep shoulder pain
decreased active + passive abduction + external
anterior knee pain in young patient - DDX (typical patient)
- patelloferomal syndrome –> young female athletes
- patellar tendonitis –> 1ry athletes (jumper’s knee)
- Osgood-Schlatter disease –> preadolescent/adolescent, recent growth spurt
patellofemoral syndrome - test
- pain elicited by extending the knee while compressing the patella
- reproduction of pain with squatting
- -> if doubt –> x-ray or f
patellofemoral syndrome - initial management
activity modification, NSAID and stretchig and strengthening exercises
- if fails after 1 year –> surgery
patellofemoral syndrome - clinical features
sabactue chronic pain increased with squatting, running, prolonged sitting and using stairs
patellar tendonitis - clinical features
episodic pain + tenderness at inferior patella
osgood schlatter - clinical features
anterior knee pain / reproduce pain when extend the knee against resistance / tenderness and edema on tubercle
- anterior soft tissue swelling, lifting of tubercle from the shaft, irregularity or fragmentation of the tubercle
iliotibial band syndrome
overuse injury of lateral knee that occurs primarily in runners
- 2ry to friction of iliotibial band against LATERAL femoral epicondyle
- tenderness at the lateral femoral condyle during flexion and extension
motor neuroma syndrome - treatment
conservative, with metatarsal support or padded shoe internts
pes anserinus pain syndrome
sharp, localized pain and tenderness over the anteromedial part of the tibial plateau just below the joint line of the knee
- normal x-ray
valgus stress will not aggravate pain
DDX of myopathy (also ESR and CK)
- Glucocrticoid-induced myopathy - both normal
- Polymyalgia rhematica - increased ESR
- Infl myopathies: both increased
- statin induced myopathy: CK elevated, normal ESR
- hypothyroid myopathy: CK elevated, normal ESR
myopathies with normal ESR and high CK
- statin induced
2. hypothyorid
Glocorticoid induced myopathy - features
- progressive proximal muscle weakness + atrophy
- NO PAIN OR TENDERNESS
- Lower ext are more involved
- normal ESR + CK
infl myopathies - features
- muscle pain, tenderness + proximal muscle weakness
- skin rash + infl arthritis may present
- high esr + CK
statin induced myopathy - features
- prominent muscle pain/tenderness with or without weakness
- rare rhabdomyolysis
- normal ESR, high CK
hypothyroid myopathy - features
- muscle pain, cramps, weakness involving the proximal muscles
- delayed tendon reflexes, myoedema
- casional rhabdomyolysis
- normal ESR, high CK
rotator cuff tears - etiology / how to confirm diagnosis
- after fall on outstrectehd arm
- MRI
rotator cuff tear - treatment
surgery with best results if first 6 wks
olecranon bursitis
due to repetitive pressure or friction on the elbows –> posterior wlbow pain and is usually associated with visible swelling of teh bursal sac
De Quervain tenosynovitis
classically affects new mothers who hold theri infants with thumb outstreched (abducted/extended). The abductor pollicis longus and extensor pollicis brevis tendons are affected
- passive stretch of these tendons elicits pains (Finkelstein test)
causes of chronic low back pain
- mechanical
- radiculopathy
- spinal stenosis
- inflammatory
- metastatic
- infectious
mechanical back pain - mechanism
muscle strain, spasm. degenerative arthritis
mechanical back pain - clinical clues
- normal neurologic examination
- negative straight leg raise
- possible paraspinal tenderness
herniated nucleus pulposus/disc disease - clinical clues
- radiculopathy (usually L4-L5)
- possible (+) straight leg raise
- possible neurologic findings
spinal stenosis - clinical clues
- pseudoclaudication
- better with spine flexion / worse with extension
- older age
compression fracture - clinical clues
- older
- More common in women
- trauma/fall (may be minor)
inflammatory - low back pain - examples
ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD
inflammatory - low back pain - clinical clues
- better with activity
- no improvement with rest
- gradual onset
- HLA-B27
malignancy - low back pain - clinical clues
- history or malignancy
- older than 50
- worse at night
- unintentional weight loss
- cauda equina syndrome
infectious low back pain - clinical clues
- Recent infection
- IV drugs
- DM
- Fever exquisite point tenderness
Disseminated gonococcal infection - clinical presentation
Purulent moroarhtirtis AND/OR
TRIAD of tenosynovitis, dermatitis (erythematous papules + pustules) asymmetric migratory polyarthralgias
Disseminated gonococcal infection - diagnosis
- blood culture (may be (-)
- synovial fluid analysis: infl effusion with neutrophil predominance, gram stain + culture or NAAT
- Culture or NAAT of urethral, cerivx, pharynx, rectum
Disseminated gnococcal infection - treatment
- IV ceftriaxone, swtich to oral (cefixime) when clinically improved)
- empiric azithromycin OR doxycycline for concomitant chlamydial infection
- Joint drainage for purulent arthritis
Management of low back pain
- acute pain 1. maintain moderate activity 2. NSAID or acetaminophen 3. consider muscle relaxants, spinal manipulation, brief course of opioids
- chronic: intermittent use of NSAID, exercise therapy, consider duloxetine / TCA
- 2ry prevention: exercise therapy, education
Bechet - manifestations beside the triad
skin lesions (erytema nodosum, acneiform lesions) 2, thrombosis
Bechet - evaluation
Pathergy: exaggerated skin ulceration with minor truama (eg. needlestick)
2. biopsy: nonspecific vasculitis of different sized vessels
characteristic of SLE oral ulcers
PAINLESS
typical age of onset of RA
30-50
RA - future complication
osteoporosis
part of spine affected by RA
only cervical
before initiation of MTX - check for
HBV, HCV, TB
fibromyalgia - treatment
exercise is the foundation
- medication (TCA, SNRI) if fails initially
giant cell arteritis vs polymyaglia rhematica regarding steroids dose
giant cells: high dose
polymyalgia: low dose
cryoglobulinemia - types and disease association
type 1: lymphoproliferative or hematoogic (eg. MM)
mixed: chronic HCV, HIV, SLE
cryoglobulinemia - types and complement levels
type 1: normal
mixed: Low C4
cryoglobulinemia type 1 - clinical findings
asymptomatic
hyperviscosity (blurry vision) thrombosis (Raynaud)
Livedo reticularis, purpura
mixed cryoglobulinemia - clinical manifestations
- fatique, arthralgia
- glumerulonephritisis
- HTN
- dyspnea, pleuristy
- Palpable purpura, leukocytoclastic vasculitis
disease-modifying antirhematic drugs - agents and SE
methotrexate: liver tox, stomatitis, cytopenias (macro anemia)
2. leflunamide: liver tox, cytpoenias
3. Hydroxychloroquine: retinopathy
4. sulfasalazine: liver tox, stomatitis, hemolytic anemia
5. TNF inhibitors: infection ,demyelination , malignancy, CHF
another difference of 1ry vs 2ry raynaud
1ry: symmetric
flexion in lumbar herniation
makes it worse
Giant cell - clinical sign if there is upper arm claudication
bruits in subclavian or axillary areas
Giant cell arteritis - treatment
- polymialgia rheumatic only: low dose oral steroids
- giant cell arteritis: intermediate to high dose oral steroids (prednsisone 40-60mg/d)
- with vision loss: high dose steroids (methylpredinisolone 1000 mg/d) for 3 days and then intermediate to high dose oral steroids
herniated disc vs vertebrae fracture - a clinical sign
hernaited disc has sciatical pain
Dupuytren contracture
progressive fibrosis of the palmar fascia and presents with a palmar nodule or thickening (usually 4th and 5th digits) with possible nodule formation along the flexor tendons near the distal palmar crease –> decreased extension
MCC of asymptomatic ALP elevation
Paget
other extramuscular manifestations of dermatomyositisi
- interstitial lung disease
- dysphagia
- myocarditis
joint fluid characteristics
- normal: clear, less than 200 WBC, les than 25% OMNs
- noninflammatory (OA): clear, 200-2000, 25% PMNs
- inflammatory (crystals, RA etc): translucent or opaque, 2000-100, often more than 0% PMNs
- septic joint: opaque, 50.000-150, more than 80-90%
Felty syndrome
- RA (vasculitis, rhematoid nodules, severe erosive joint disease + deformity)
- neutropenia (ANC less than 1500)
- splenomegaly
IN 10 YEARS RA
enthesitis as isolated disorder?
plantar fascitis
indications for imaging in low back pain - x-ray
- osteoporosis, compression fracture
- suspected malignancy
- anklylosing spondylitis (eg. insidious onset, nocturnal pain, better with movement)
indications for MRI in low back pain
- sensroy/motor deficits
- cauda equina
- suspected epidrual absecess/infection
indications for radionuclide bone scan or CTn low back pain
indications for but not able to have MRI
Baker cyst - complications
- venous compression (leg/ankle swelling)
- dissection into calf (erythema, edema, positie Homan sign)
- Cyst rupture (acute calf pain, warmth, erytema, ecchymosis)
- crescent sign distal to medial malleus
