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MSK Conditions – Clinical Integration Condition Description Pathophysiology Clinical Presentation & Findings Management and Prognosis or Notes Cervical Spine Bones Dens (C2; axis) Fracture Most common upper spine fracture, car accidents, falls Occurs at base of dens post. displacement of dens toward spinal cord X-ray/CT cord injury in 15% cases; blood supply iffy so delayed healing/non-union Hyperflexion Teardrop Fracture Triangle shape frag avulsed; Severe flexion force (head on car crash) Ant. longitudinal lig pulls on anterior vert. body; avlusion frag attached to lig. Rest of vert. body is distracted posteriorly water drop on CR C5 body post. displaced tear drop attached to lig subluxed facets compress cordneuro injury Most serious cervical spine injury. unstable Fx w/ little chance of neurological improvement Extension Teardrop Fracture Ppl fall and hit face; C2 or C3 common sudden hyperextension, ant. longitudinal lig avulses bone frag from anterior inferior margin Fx often stable and NOT result in cord injury

MuSK Conditions

Dec 26, 2015



Robert Maciel

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Page 1: MuSK Conditions

MSK Conditions – Clinical Integration

Condition Description Pathophysiology Clinical Presentation & Findings Management and Prognosis or Notes

Cervical SpineBonesDens (C2; axis) Fracture

Most common upper spine fracture, car accidents, falls

Occurs at base of dens post. displacement of dens toward spinal cord

X-ray/CT cord injury in 15% cases; blood supply iffy so delayed healing/non-union

Hyperflexion Teardrop Fracture

Triangle shape frag avulsed; Severe flexion force (head on car crash)

Ant. longitudinal lig pulls on anterior vert. body; avlusion frag attached to lig. Rest of vert. body is distracted posteriorly

water drop on CRC5 body post. displacedtear drop attached to ligsubluxed facetscompress cordneuro injury

Most serious cervical spine injury. unstable Fx w/ little chance of neurological improvement

Extension Teardrop Fracture

Ppl fall and hit face; C2 or C3 common

sudden hyperextension, ant. longitudinal lig avulses bone frag from anterior inferior margin

Fx often stable and NOT result in cord injury

Vertebral Axial Load Burst

Vert. body compressed both anteriorly and posteriorly.

From traumatic injury –vert. body “explodes” from high-energy axial load; falls from heights

Pieces of vertebra can displace into surrounding tissues and spinal cord

Often injures cord of cauda equine

Jefferson Axial Load Burst

See above Direct blow to top of headfx ant. and post. arches of C1 (atlas)

Can see breaks between the lateral masses and the arches; CT

InjuryC1 expandsso uncommon to injure cord


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Cervical Degenerative Disk Disease (OA)

Normal aging process, disk loses flexibility and shock absorbing func; start age 25

Nucleus pulposus loses [proteoglycans] that bind waterdehydrates. Also [Collagen] in ECMbecome white and firm.height diskchange vertebrae alignment pressure on Vetebral endplates get sclerosed, form osteophytes. (in attempt to grow extra bone)Progress to tears in annulus fibrosis.Misalignmentsublux facet joints; not supported, get OA at facet joints; progressive cycle

Eventual neck pain assoc. w pathologyLoss normal cervical lordosis bc paraspinal muscle spasm in response to painROM: normal to limitedlocal tenderness over paraspinal muscles and over cervical vertebra; otherwise pain not reproducible w palpation

CR: narrowed disk spaces, osteophytes, bone sclerosis

NSAIDs, opioids severeStrengthen paraspinal muscles for support, stretchingIf severe, surgical cervical spinal fusion

PROG: progressive w/ age and additional trauma

Cervical Disk Herniation

Normal aging as disc degenerates

Microtears in annulus fibrosis inflammation in surrounding tissue and nucleus pulposus protrudes from tear.Typically posterolateral pathway –bc flexion of spine creates ant. compression, pushing pulposus posterior-can compress nerve roots (cervical radiculopathy)OR directly compress spinal cord (cervical myelopathy)Inflamm alone may affect nerve roots…

-local neck pain midline or in cervical paraspinal muscles; worse w movement-if radiculopathy, sharp shooting, tingling, numbness, aching, heaviness sensation radiation to shoulder and/or upper extremity, eventual muscle atrophy in myotomal pattern-if myelopathy, weakness,muscle tone, spasticity in legs, hyperreflexia lower limb -Cervical muscle spasms and loss of normal lordosis-abnormal gait bc of weakness/spasticity in legs-ROM limited bc of pain-Spurling’s Test + for nerve root compression , MRI /CT confirms diagnosis

-NSAIDS, opioids; muscle relaxants-Epidural Corticosteroid injection pain relief-relaxation and ROM exercises, postural training,-traction for temp relief of compression-Ice/Heat compress to alleviate muscle spasm/pain

PROG: most resolve w/in 6 wks. More complicated if radiculopathy or myelopathy

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Muscles/TendonsCervical Muscle Strain

Injury of muscle from incorrect exertion or overuse. Most common reason for neck pain/headaches

Tension in post. Cervical parapsinal muscles which compress greater occipital nerve (C2 dorsal rami)

- Acute onset sharp/aching/throbbing pain localized to posterior neck, worse w movement; pain can migrate to headheadaches-loss of cervical lordosis bc muscle spasm-ROM: limited bc of pain/stiffness-reproducible pain w palpation of muscle-no CR unless trauma

-NSAIDs-Ice during acute painful period (1st few days),-Neck bracing temporary (1-2days) to rest muscle ,-Superficial/deep heat (days to weeks after injury)StretchingPROG: most recover shortly

Whiplash Syndrome Usually from a car accident caused by sudden force

Rapid and extreme ROM btwn hyperflexion/ hyperextension injures facet joints, ligaments, muscles

-Deep aching, sharp, throbbing neck pain, from base of skull to cervicothoracic junc of spine ; worse w movement-potential pain in trapezius, SCM, or headaches- paraspinal muscle spasmloss lordosis; tender muscles; tender along spinous process- ROM: limited bc pain,-CR in flexion/ext to rule out vertebral fractures and spinal instability

-NSAIDs, opioids, muscle relaxants-ACUTELY: Cervical collar, ice massage

PROG: 80% full recover 3 mo, 20% have continued pain bc chronic muscle spasm or ligamentous instability

LigamentsAtlantoaxial Instability

High risk pts: Down syndrome (congenital laxity), RA (structural damage); or trauma in general

mobility of atlantoaxial joint btwn anterior arch C1 (atlas) and dens C2 (axis) –-abnormalities of transverse ligament; dens moves posteriorly and may compress cord

Many asymptomatic.Symptoms w/ subluxation of denscompress cordneuro problems: weakness/sensory impairment in arms/legs, tone, hyperreflexia, abnormal sensationsudden cord compression => deathROM: limited to pain,Midline deep pain bc of paraspinals spasm-CR –predental space, normal 3mm; distance posterior surface ant. arch C1

-NSAIDs, opioids-Surgical fixation-detect early in high risk ppl–and avoid neck manipulations or high impact exercises

PROG: fine if treated w/ surgical fixation but bad if not and can cause death

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(myelopathy) and anterior surface dens (C2)Nerves/VesselsCervical Radiculopathy (see chart of dermatomes at end)

-C6 and C7 most common-dermotome sensory changes; radiate shoulder and upper extremity

Root compression in spinal canal or neural foramen from:1) herniated disc or osteophytes2) inflammation in soft tissues surrounding; most commonly from tears annulus fibrosisrelease cytokinessinuvertebral nerve contain sensory nerves (nociceptive) to these tissues (post. long lig, ligamentum flavun, peripheral fibers annulus fibrosis, VSM, dura mater, periosteum of spinal canal

-parasthesia (numbness, tingling, prickling) in dermatome pattern of root-motor deficit if affect ventral motor root fibers also-cervical parapsinal muscle spasm,ROM limited as extension compressionpain-local tenderness over paraspinals from spasm but palpation in extremity should NOT reproduce pain-Spurlings-EMG: assess degree damage-CR may help w cause compression or MRI

-NSAIDS for inflammation, antidepressants, anti-seizure meds for neuropathic-Cervical traction, stretching,-epidural corticosteriod, -surgerical excision of herniated disk, osteophytes

PROG: fair –most improve w/ conservative treatment

Cervical Spine Stenosis

Narrowing of the cervical spinal canal

-disk herniation, osteophyte on vertebral end plates, hematoma after trauma, tumor, foreign body-if significant narrowingcan get compression of roots (radiculopathy) or of cord (myelopathy)

Neck pain, gradual onset of pain wks to months, and neck stiffness, tenderness over cervical paraspinal muscles and midline-Cervical muscle spasms, loss of lordosis, -if cord compressed, abnormal gait or bowel/bladder incontinenceROM limited bc pain , neck extension painful- avoid as compression-Spurlings: + implied radiculopathy-EMG: degree involvement-Sensory/motor reflex testing---if radiculopathy: sensory abnormal, upper extremity weakness, reduced reflexes----if myelopathy: muscle tone, reflexes (patella/Achilles) and sensory abnormalMRIcanal size, etiology, cord compress

-NSAIDs, opioids, oral corticosteroid for acute pain/weakness-corticosteroid injection,-excision of osteophytes/ herniated diskPROG: herniation good , on its own, others, need treatment or surgey (remove tumor or foreign body) (aimed to prevent progression, not reverse deficits)

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Lumbar SpineBonesSpinal Compression Fx-Osteoporosis

Typically at thoracic level and thoracolumbar junc

Vert. body compression fxcollapsing crushing of boneheight vert body

At risk: osteoporotic/post-menopausal women, elderly men, long-term steroid med users, young person from traumaSudden pain in young personOlder pt w osteoporosis may have vague pain, but might not noticeAvoid corticosteroids in compression fx; bc they weaken bones/ligs

Spinal Compression-Traumatic

See above See above Often due to fall from height – land on buttocks or feet. collapsed the area painNormal T10Compression fx T11

Spondylolysis 5% pop, more common athletes: gymnasts, football linemen who hyperextend of spine.

Fx of pars interarticularis (btwn superior and inferior articular processes of vert.) usually L5/S1If bilateral break can have listhesis too

-Scotty Dog “neck collar” break on CR- low back pain , over L5 usually-hamstring tightness, limited forward bending-Antalgic gait (abnormal as result of pain), reactive muscle spasm-ROM: limited spine extension bc of pain

NSAIDS, muscle relaxants-surgical fusion in extreme-stretching of back/legs-posture correction-lifting techs, strengthen core muscles (back/abs)

PROG: w/o spondylolisthesis; usually good w/ conservative treatment


NOTE: spondylosis: refers to any conditions of spine

Slipping caused by spondylolysis in young ppl OR OA in old ppl

Vertebral body slippage fwd onto vert body below from broken parsOR in degenerative disk disease: disk

Stable: slippage unchanged in flexed or extended position;Unstable: slippage degree changes when flexed compared to extended; ex. Sheering force involved if changes when

PROG: w severe, unstable spondylolisthesisNEED surgery

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heightlaxity in supporting ligsallows vertebral slippling. Stable or unstable

sit to stand position-Rest – see above

JointsLumbar Degenerative Disk Disease (OA)

See Cervical OARed arrow: disk space narrowingBlue arrow: sclerosis and ostephyte adjacent to disk spaceGreen: sclerosisOrange: osteophytes from narrowed facet joint spaces

-see Cervical OA -pain midline, worse w/ movement, weight bearing activity and back extension once facet joints involved-loss of lordosis from paraspinal muscle spasm, ROM: normal to limited,-local tenderness over paraspinals from spasm-pain from OA is NOT reproducible by direct palpation-CR narrowed intervertebral disk space, sclerosis/osteophytes-MRI desiccated disk

-NSAIDs, opioids-Weight loss-gentle ROM exercises-posture/lifting techs-strengthen paraspinals and ab muscles-if severe, stiffness + extreme pain, surgical fusionPROG: poor, will progress w/ age and additional trauma

Lumbar Disk Herniation

Tears in annulus fibrosis1) inflammatory response affecting adjacent tissues2) nucleus pulposus protrusion;Typically posterolateral pathway (post. long. Lig thinner) so disk herniates around it

NOTE: in lumbar L3/4 herniation, affects L4 nerve; L3 manages to come out

-local low back pain midline or lumbar paraspinals, worse w/ low back moving-if lumbar radiculopathyradiating pain to butt/lower extremity; abnormal gait-if compress thecal sac, (cauda equine syndrome) bowel/bladder incontinence, weakness, muscle tone, loss of normal sensation /reflexes in legs bc affect lower motor neurons (vs cervical herniation which affected upper motor neurons and saw muscle tone in lower extremities)-Bilateral muscle spasms, loss lordosis ROM limited bc pain, muscle atrophy,-Spurlings maybe + if nerve root

-NSAIDs, opioids, muscle relaxants-Corticosteroid injection in epidural space-relaxation ROM exercises,-postural training, traction, Ice/heat for muscle,

PROG: most resolve w/in 6 wks; more complicated in neuro involved

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above herniation compressed-MRI/CT to confirm dx

Sacroiliac Joint Dysfunction

Change in alignment of SI joint;Anterior sacroiliac lig; posterior sacroiliac lig; sacrotuberous lig; sacrospinous lig

∆s in SI ligaments that normally provide stability–can shorten/tighten from sedentary, can get lax during pregnancy from hormones, can get uneven joint surfaces and fuse bc of degenerative aging ∆s , stress from imbalance of surrounding musculature

-gradual low back/buttocks deep aching pain, progressive w/ hip movement, , can radiate to anterior/posterior thighpain w/ hip flexion, abduction, external rotation on same side walking, standing, and weight bearing-Reproducible w/ palpation over SI ligs near PSIS-Leg length test, FABER test-CR usually normal

NSAIDs, ice in acute, deep heat/US in chronic, gluteal/paraspinal muscle strengthening-Corticosteroid injectionPROG: good: self limiting usually, need early treatmentFair to poor: if misdiagnosed/treatment delayedchronic, debilitating conditon

Scoliosis Lateral curvature of spine. Usually thoracic and lumbar regionsGirls 7x>boys

Rotation of vertebrae, single C curve or double SConvex to right: dextro- Convex to left: levo-Idiopathic in kidsAdults: 2° to spondylolysis/-listhesis, OA, stenosis, compression fx due to osteoporosis

Kids: Curvature usually not noticeable until > 20°, usually no symptomsAdult: pain localized to reg. of deformity-Asymmetry of spine when pt bends fwd, Rib cage/scapula higher one side, asymmetric waist lineROM normal,local muscle tenderness in curvature area from spasmCR to confirm degree of curvature

<10° no treatment20-30° monitor,brace (prevents further, wont correct)>40° or if breathing difficultysurgical fixPROG: progressive until puberty then stabilizes. Adults: progresses w/ degeneration

Ankylosing Spondylitis

Ankylosing (joint fusion) spondylitis (spinal inflammation) Chronic seronneg. Spondylo-arthropathy w/ axial involvement (SI and spine), Class I HLA-B27 strong associationMore men,

Begin young adult, in SI joints (sacroilitis). Pannus forms, erodes fibrocartilagentous jointossification and bony fusion (ankylosis)-Progressive stiffening of spine w/ fusion.Enthesitis (inflamm tendon and lig insertions into bone)

-low back pain, worse w/ rest but pain w/ activity (NOTE: opposite of OA); morning stiffness ~30min-enthesitis: accounts for pain, stiffness, and restriction at SI and spinal joints; also at Achilles tendon and plantar fascia-No lab test diagnostic for AS+ HLA-B27 useful but NOT dx bc many +, not all get AS-CR EARLY: SI normal MIDDLE: SI joints widened END: sheets of ossification obscure joint

NSAIDS,Early dx – to relieve back stiffness, good posture, ROMPROG: mild to severe – cant predict the disease progression

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typically 20-30YO -Bamboo spine squaring of vert body and fusion of adjacent levels, calcification of spinal ligs

Muscles/TendonsLumbar Muscle Strain

Incorrect exertion or overuse. Most common reason for low back pain.

Correlated w stress, tension, continual awk back positions.

Acute onset sharp, aching, throbbing pain, localized to posterior back and buttock, worse w/ back movements, can migrate.-muscle spasm loss of normal lumbar lordosis, ROM limited to pain/stiffness, pain reproducible to palpation of affected back muscle.No CR unless trauma

NSAIDs, Ice acute, temp back bracing 1-2 days to help rest msucles; do NOT brace >2-3days bc atrophy and deconditioningChronic/subacute: deep heat; stretchingPROG: most recover spontaneously w/in days to weeks

Nerves/VesselsLumbar Radiculopathy

SEE dermatome/ myotome patterns at end

Compression or injury to spinal nerve rootsL5/S1 most common

NOTE: if L4/L5 level, if impinge at foramenaffect L4; if impinge in cordaffect L5 which exits below

Osteophyts or herniated disk compressing in nerve roots in canal or neural foramen.Tend to radiate to gluteal and lower extremity. See cervical radiculopathySinuvertebral nerves have nociceptive fibers producing the pain signal from inflammation

Paresthesia (neuopathic) in dermatomal pattern; potential muscle weakness if ventral roots affectedPainful antalgic gait, muscle spasm lumbar paraspinals. ROM limited as extension compression.Local palpation in extremity NO reproduce pain. Local tender over paraspinals though-Straight leg test, EMG assess-can produce Sciatica symptoms, but radiculopathy not only cause sciaticaCR rule out cuase. MRI better

NSAIDs for inflamm, antidepressants, anti-seizures for neuropathic pain-proper posture, lifting techs, lumbar traction, stretch muscle spasm, improve paraspinals and abs. Muscles for stability Epidural for pain relief, excision of herniated disk.PROG: fair; conservative treatment

Lumbar Spinal Narrowing of See Cervical Spinal -gradual onset of back pain and stiffness -NSAIDs, opioids, oral

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Stenosis lumbar spinal canal.

Stenosis. Various causes can result in compression root (radiculopathy) or cauda equine (cauda equine syndrome)

lower extremity wkness, sensory abnormal, bowel/bladder incontinence (cauda equina)suspect stenosis if bilateral radiculapthy w or w/o bowel/bladder symptomswalk w/ fwd flex (stooped) position-opens canal and relieve some symptom-Oppositie of cervical stenosis: here have muscle tone and reflexes in lower extremities-loss lordosis, ROM limited to pain, esp back extension bc canal size, tender over paraspinals/midline from 2° spasmStraight leg test + if radiculopathySensory/motor/reflex testing is KEY to assessing neuro involvement, MRI

corticosteroids-epidural corticosteroids-if severe decompression surgery/excision to prevent further compression/damage-myeloradiculopathy: herniated disk cause both radiculopathy and cord compression-Upper Motor Neuron spasticity, Babinski sign present w/ spinal cord compression need to treat!

Shoulder RegionBones-FracturesHumerus Surgical Neck Fracture

Most common proximal humerus fracture. Old ppl w/ osteoporosis at risk.

Falling on outstretch hand or direct impact to shoulder. Axillary nerve most commonly injured

. Sensory ∆s over deltold muscle and weakness w/ abduction of shoulder joint (bc axillary nerve innervates delt)-EMG (electromyogram) and NCS to diagnose nerve damage-CR for fracture

Humerus Midshaft Fracture-Pathologic

Weakened bone from pathologic lesion

Trivial pressure causes fracture. Benign/malig neoplasms, osteomyelitis, paget’s. Risk injury to Radial nerve

-if radial nerve injured, lose sensation over dorsum of hand and weakness w/ wrist extension.-EMG and NCS to det. Nerve damage-CR for fracture

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Clavicle Fracture Most common childhood fracture (incomplete ossification til teens)

Direct force applied to lateral aspect of shoulder – fall onto outstretched hands or car accident.

80% mid-clav, medial to coracoclavicular lig; proximal frag typically displaced upward bc of pull of SCM muscle.-CR for fracture

JointsShoulder instability and Dislocation

Anterior dislocations most common. Football and volleyball players; Shoulder joint depends on depth glenoid cavity from labrum, joint capsule, capsular lig, and rot cuff to stabilize bc only 1/3 humerus head on glenoid

Ligament laxity –shoulder subluxation (partial instability) or dislocation, Direct force of repeated activity causing abduction and external rotation of shoulder joint. Inferior glenohumeral lig most commonly gets laxant. Dislocation. Posterior disloc – acute trauma to anterior shoulder (football lineman) posterior force

-asymptomatic till injury-overworking of rotator cuff/shoulder muscles trying to stabilize joint chronic muscle spasm, diffuse aching pain-if actual dislocatesevere sharp pain w/ move-shoulder exam normal, but local tenderness (traps, rhomboids, rotator cuff)-Obv asymmetry/deformity, ROM very limited both passive and active-CR to see position of humeral head, but often normal in pts w/ shoulder instability w/o dislocation-positive sulcus sign

-NSAIDs, if severe Opioids-Joint reduction/relocate to avoid neuro/vascular injuries,-strength training for surrounding muscles, avoid shoulder abduction/ext (tennis/ volleyball serve, throwing)--after one disloc.more prone to another(Apprehension test: abduct, bent elb, passive ext. rot; pt hesitates)Prog: good if no neuro defects and labrum intact; if notrepeat dislocate possiblw

AC Joint injuries(acromioclavicular)

Fall or blow to top of shoulder

Acromion driven to groundAC sprain –CC ligs ok, but injury to AC ligs (grade I)AC separation –both AC and CC ligs injured – partial sep (grade II) of clavicle from acromion. If complete

Sprain –swelling, tenderness, some loss shoulder movement (esp aDduction)AC separation –severe pain esp w/ move-asymmetry of shoulders, bump/high riding tip of clavicle in AC joint separation-painful to touch AC joint, limited ROM-CR for pos of acromion and clav, distance of AC joint space. Can take CR w

-NSAIDs, opioids-rest and arm sling for sprain, maybe surgery for separationProg: normal joint fxn 6-8wks w/ cons. treat,

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separation (grade III) downward traction of arm w weights to show dist.

might have residual bony callus over AC joint (think lori)

Adhesive Capsulitis Frozen shoulder. 40-70YO, 3% pop. males less affected than females; wide spectrum of limited ROMcapsule has tightened up; compare to other side to eval

Chronic immobility, scarring, thickening of joint capsule, progressive loss ROM. 2 types:1) No prior shoulder condition – but stroke, muscle weakness, brain injurylimited movement2) prior injury– shoulder impingement, OA, surgery

-deep dull aching pain and stiffness of shoulder joint. Onset gradual and w/ shoulder move. Difficulty sleeping on affected side-shoulder looks normal/symmetric-ROM decreased actively and passively. External rotation first to be affected.-diffuse tenderness over ant/post capsule-CR usually normal, but rule out other dx -MRI can show scarring capsule, but not needed for dx

NSAIDsPT – stretching program, US heat, ROM exercises-Glenohumeral joint injection w/ lidocaine and corticosteroidProg: good w/ early intervention. Prevention is key! Don’t prolong immobilization

Muscles/TendonsShoulder Impingement Syndrome

AKA-rotator cuff tendonitis-supraspinatus tendonitis-subacromial Bursitis,-calcific bursitis-tendonitis

Degen. process of shoulder from overuse or previous injury. Ischemia to Rot Cuff tendonsmicrotears, initates inflamm response to repairvascularization (granulation tissue) and deposit Ca++ crystalscalcification collects under subacromial bursalead to more inflamm (calcific tendoinits or bursitis) eventually leads to full rotcuff tearmore inflamecytokines can erode bonedamage

Gradual onset of ant/lat shoulder pain hurts when reach overhead-night pain, cant sleep on affected side-Shoulder looks normal, unless can see atrophy in supraspinatus, ROM limited in aBduction and flexion >90 deg, pain w Int rot w/ arm abducted (Hawkins) or flexed (neer’s)-tender over point of shoulder & laterally near subacr. Burs+ Hawkin’s sign, + Neer’s signCR- can see complete tear, not partial; see joint space narrowing; sclerosisUS-if operator good, can see tearMRI-show tear

NSAIDs, opioids-in acute stagesice to ant/lat shoulder,-in chronic deep heat-don’t reach overhead, no flex or aBduct >90°-passive ROM needed to prevent adhesive capsulitis,Corticosteroid injectsubacro. bursaSurgical excision of part of acromion to prevent compression of supraspinatus tendonProg: most resolve w/ conservative treat.

Nerves/Vessels: Peripheral Nephrapthies

NOTE: paresthesia: skin sensation, such as burning, prickling, itching, or tingling, with no apparent physical cause

Thoracic Outlet Compression of Dev. Anomalies – cervical Pain and paresthesia along ulnar aspect Home exercise program

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Syndrome lower trunk of brachial plexus or subclavian vessels as they course btwn clavicle and 1st rib.

rib/long transverse process C7, posttraumatic fibrosis of scalenes, women 20-50 most common

of forearm, and medial 2 fingers.-IF vascular compression – intermittent swelling & discoloration of arm that worsens when arm is raised over head.

that promotes muscle strengthening and correct posture

Brachial Plexopathy Nerve traction injury to shoulder. Weakness and sensory loss depend on degree and location injury.

Most COMMON: brachial plexus upper trunktraction force to C5-C6 roots when shoulder forcibly depressed while head/neck tilted opposite side. In children C5-C6 –Erb’s palsy-baby when giving birthBurner’s/Stingers transient injuries C5-C6 rootKlumpke’s palsylower trunk injury; traction force (C8-T1) when falling from height (grabbing ledge)

Erbs arm hangs useless at side from shoulder girdle/biceps paralysis. Also loss sensation at wrist Waiter’s tip deformity; not really a deformity of the handCollege athletes, football players

Claw hand-intrinsic muscles of hand affected (lumbricals and interossei), so finger flexors (FDS and FDP) are unopposed.; 4th and 5th digit

Poorer prognosis

Suprascapular Nerve Entrapment

Purse neuropathy –pressing against upper scapula

Suprascapular nerve from upper trunk brachial plexuscourses across post. Trianglebeneath suprascap. Lig and if pressure on lig, then nerve gets entrapped

Sensory fibers – post aspec of shoulder joint => dull shoulder pain when nerve entrapped. No neck pain, maybe some shoulder movement weakness

Radial Nerve Entrapment-Upper arm

Radial nerveterm. branch of post. cord

- Crutches at the armpit/axilla-compression in radial groove deep to triceps , Sat. night palsy (ex. Arm over back of chair entrap along post. Humerus)

--@axillaElbow ext. (triceps) weakness, sensory abnormal in posterior arm/forearm-@radial groovesensory ∆s on radial side of forearm, wrist, and dorsum of lateral 3.5 fingers (not tips) Motor: cant extend wrist, thumb, and fingers so hand droops. Wrist drop

Elbow, Wrist, HandBones-Fractures/

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DislocateSupracondylar Fracture

Distal humerus proximal to epicondyles; common and serious in childrenhigh risk neurovascular problems

Fall on out-stretched hand w/ elbow joint in hyperextension

damage median, radial, and ulnar nerve.Compartment syndrome in volar forearm w/ brachial artery => muscle necrosis from ischemia; can lose forearm; painVolkmann’s ischemic contractures bc muscle shorten and pulls on tendon (permanent flexion -> claw like deformity; more flexor muscles)

If malreduction, elbow can get deformed and deviate medially called cubitus varus (abnormal carrying angle)

Ulnar Shaft fracture Policeman beating you up with his nightstick

Forearm struck by objectNightstick fracture or parryAlso falls/car accidents

Transverse, non-displaced

Radial head dislocation (Monteggia fracture-dislocation)

Fall on outstretched hand w/ forearm in excessive pronation

Fracture to prox 1/3 of ulna w/ anterior dislocation of radial head w/in proximal radioulnar joint.

Must include elbow in CR otherwise can be missed.

Radial head fracture Trauma, fall on outstretched arms

Radial head pressed into capitulum of humerusMay see displaced posterior fat pad in traumahigh prob of fracture

Greenstick fracture(like see w green sapling)

Incomplete fracture in kids

Quick twisting motion w/ axial compression (fall backwards on outstretched hands)

Cortex of bone on one side bends while other side fractures

Have to break the other side so that healing takes place properly.

Torus fracture of radius (buckle fracture)

Common in kids; rare in adults

Bones are pliable in kids, so bone bends under stressraised buckle w/o fracturing other side

Distal radius common site, can see a little nub on CR sticking out of radius; but any long bone possible

Colles’ fracture Most freq broken bone in upper

Fracture of distal radius. Break a fall on outstretched

Posterior displacement, angulation, and rotation distal frag; >50% pts also have

NSAIDS, splint if fracture in good alignment or

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extremityCommonly adults>50YOConfused w scaphoid fract…

hands or forced dorsiflexion fracture ulnar styloid process.Wrist pain, local tenderness, swellingx-ray dx;

must reduce w internal/external fixation and cast

Scaphoid fracture Most freq fractured carpal bone. More common young adult athlete

Break fall by landing on palm of handforces wrist into ext and radial deviation (abduction)force transmitted to arm via scaphoid boneIf swollen, tenderness base thumb, and no colles fxthink scaphoidsplint/protect

-Easy to miss bc no bruising & ppl think sprained wrist; pain radial side wrist-scaphoid bone forms floor of “snuff box” and fracturetenderness in area--delayed healing or non-union is BADavascular necrosis proximal frag bc blood supply normally trickles from distal half and lose w fxwrist strengthx-ray may be normal; CT or MRI may show w/in 48-72hrsCommonly missed, fx may not show up for 10days

NSAIDs, Thumb spica cast, surgical fixation if dislocate and healing poorly.

Metacarpal #5 Angulated Neck fracture

Boxer’s fracture Head of 5th metacarpal breaks and moves toward the palm forcing MCP of little finger into hyperextension (bc MCP joint is volarly displaced) and collateral ligaments get slack

Phalanx Growth plate fracture

Salter Harris fracture of phalanx; 5 possible Grades, V most serious

Typically from actue or overuse (gymnast/pitcher) or physical abuse

Always exam child complaining of pain; Don’t have work through pain

Distal phalanx fracture

Sports injuries Intra-articular fracture of distal phalanx associated w/ extensor tendon injury (dorsal) or flexor tendon injury (volar)

forced flexion of DIPtension on extensor tendonavulsion of dorsal proximal margin of distal phalanx


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Nursemaid’s Elbow see 1-3YO when adult swings child by arms or pulls on them suddenly

-Partial dislocation of proximal radioulnar joint. -Traction of arm while elbow extended; sublux radial head-Annular lig slides over head of radius and gets trapped.

-pain w elbow movement; limited ROM-Sign: holding arm in slight elbow flexion, despite no swelling and refuses to move armtenderness over elbow joint CR normal

No medsReduce joint dislocation: support radial head, suppinate and flex forearm at same time until “click”Prog: can reoccur

Wrist/Hand RA affects MCP, PIP, and thumb interphalangeal; usually spare DIP

joint fusion occurs if severe

Inflamed synovium damages flexor/extensor tendons -ulnar deviation (u drift) at MCPs of fingers--swan neck (hyperextend PIP w flexion at DIP)--boutonnier’s (flexed PIP w hyperextended DIP)

Local pain hands/fingers, in MCP/PIPs bilaterally, gradual onset deep aching throbbing in joints, pain w/ movement, swelling, warmth and morning stiffness, RA nodules (small firm nodules)Spare DIP joints; ROM limited due pain and structural damage/deformitiesCR Diagnostic

NSAIDs, antirheumatic agents, cold packs, joint protection w/ splints, paraffin wax, contrast bath, use assistive device for house work/activities, corticosteroid injections, surgery for tendon rupture,Prog: fair to poor; progressive w pain &func

Hand Osteoarthritis (OA) aka degenerative joint disease

PIP, DIP, CMC joint of thumb progressive cartilage degen--Bouchard’s nodes (bony nodule PIP joints)--Heberden’s nodes (bony nodules DIP)(bone gets damaged, so tries to repair w hypertrophynodes)

Localized pain @ base of thumb or PIP/DIPs, gradual onset pain progresses to constant pain w/ repeated hand pain; pain w/ rest and ice application -stiffness and swellingdiff to grip- joint deformity, muscle atrophy from disuse, ROM bc pain/stiffness reproducible pain over affected joints,CR: non-uniform joint space narrowing, bone sclerosis, osteophytes

NSAIDsHand therapy w/ paraffin wax and contrast baths, protective splinting, corticosteroid injectionsProg: Fair: progressive condition; provide pain relief and prevent further injry

Scapholunate Dissociation

Most common carpal instability

Tear of intercarpal ligs of lunate/scaphoid/capitate bonesabnormal movement of carpal bones wrist instability and early

Acute to gradual onset wrist pain over scapulo-lunate junc, Possible trauma from sudden wrist hyperext, or repetitive use injury. Swelling or weak grip, clicking of wrist, ROM limited especially flex/ext,

NSAIDsTemp immobilization of wrist in neutral position, surgery if pain persistsProg: fair to poor, pain

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OA tenderness over scapholunateCR may show gap btwn scaphoid and lunate >2 mm

imprv w/ treatment, but gradual loss of ROM despite surgery


Medial Epicondylitis

NOTE: Tendonitis: resist contraction or stretching it will hurt! Hurts palpate over tendon and if bad enough muscle tooCorticosteriod injection: not 1st resort, but help take away pain from inflame; yet still have deconditioned muscle so need to stretch/work muscle

Golfer’s elbow (adults) and little leaguer’s elbow (kids)

Overuse of wrist flexors/pronators of radioulnar joint. Common flexor tendon gets inflamed

Gradual prog w/ more pain over medial epicondyle that radiates to forearm. pain w/ lifting, wrist flexion pain w restUsually normal inspection, passive ROM at elbow and wrist normal, but active ROM is limited due to pain. Tenderness over medial epicondyle--Resisted wrist flexion and pronation will produce pain. passive wrist ext w/ elbow extended causes pain. CR normal unless tendon calcification

NSAIDs, PRICEStop painful activity, counterforce brace distal to elbow to distribute tension/fulcrum, brace flare on side of injury; PTCorticosteroid injectionProg: good normally resolves w/ conservative treatment and prevention future injurySurgery if no impove 6-12months

Lateral Epicondylitis ECRB tendon (extensor carpal radialis brevis) most involved bc smaller muscles worked more Tennis elbow

Overuse of wrist extensors/supinators muscles of proximal radioulnar joint . Common extensor tendon gets inflamed.

pain over lateral epicondyle, forearmpain w/ wrist lifting/ motion/extension and w/ rest,Passive ROM normal but active ROM limied to pain.--Resisted wrist ext/supination will reproduce painCR normal unless tendon calcification Same as above

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Olecranon Bursitis Resting elbows on desk while studying!! –subject elbow to acute or repetitive trauma

Swelling of olecranon bursa found btwn olecranon process of ulna and skin located in posterior elbow

Onset gradual, mod-severe local pain w/ any pressure or elbow motion, posterior elbow pain. if acute, pain might be sharp and radiating to posterior forearm,Soft tissue swelling over olecranon, maybe erythematous ROM limted to pain, posterior elbow tender.CR usually normal

NSAIDsPRICEApsiration –can reduce swelling or rule out septic bursitis or gout

Prog: most recover spontaneously

DeQuervain Tenosynovitis

Distinguish from OA bc if DeQuervain severe enough cause pain along entire tendon and not just base of thumb like OA does

Often confused with OA of CMC joint of thumb

Inflamm of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) (SEX LAB) on radial side of wrist. Repetitive/cumulative trauma to tendons from repeat ext/aBduction of thumb. When tendon sheath healsget dense fibrous tissue that thickens sheath and obstruct tendon movement.

Pain/tender on radial side of wrist over radial styloid process and at CMC joint of thumb.-Constant throbbing aching w/ superimposed sharp pain during thumb movements. Pain iw/ pinching, grasping, making fists. w/ rest, heat/ice-Swelling over distal radius, limited ROM in thumb and wrist; Crepitus palpable when pt. flexes actively and extends. Finkelsteins’ testreproduce pain when pt bend thumb across palm, close fingers over thumb making fist, and ulnar deviate the fistCR to rule out OA

NSAIDsRest thumb/wrist, avoid repetitive wrist motions, thumb spica splint to immobilize tendonsCorticosteroid injection , sometimes surgProg: good – full functioning after treatment. Normal activity after 3 weeks

Trigger Finger Palpable/audible snapping when pt flex/extends fingers. More often women > 40 w/ hx of diabetes or RAUsing gardening shears

Presence of inflammation of FDS (flexor digitorum superficialis) or FDP (flexor tendon profundus) tendon sheaths of fingers (tenosynovitis). Tendon sheath swells and gets caught in narrow osteofibrous sheath anterior to MCP

Gradual onset of mild-mod pain pain after prolonged period of inactivity or repeated activity of hand that involve gripping or tappingSwelling and small nodule at MCP, extension limited to pain, fingers tend to lock as they extend, nodules might be palpable over MCP joint in palm, tender.CR normal

NSAIDsRest finger w/ or w/o splint, treat inflammaCorticosteroid injection swelling in sheathSometimes surg to widen osteofibrous tunnelProg: good – most improve w/ conserv treatm

Nerves/VesselsCarpal Tunnel Most common Median nerve compressed Dull aching pain in wrist might extend to NSAIDs, opioids

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NOTE: if nerve pain, palpation of muscle will not reproduce pain unless pushing on nerve

Tingling and numb of thumbCarpal tunnel OR C6 radiculopathy?Tinel +carpal tunnelC6other symptoms also (widespread sensory/motor symptoms; numb C6 dermatome, muscle weakness deltoid/biceps, +spurling test)

compression neuropathy in upper extremityTyping, hairstyling, gardening

10 things in carpal tunnel: 4 FDS, 4 FDP, median nerve, flexor pollicus longus tendon

under transverse carpal ligament (flexor retinaculum) forming roof of carpal tunnel. Pain/tingling/numbness/burning in thumb, index, middle finger

nerve will die from compression and if nerve dies, nothing controlling muscles, so muscles atrophy

forearm and arm; MOTOR +Sensory-thumb/index have paresthesia, esp on wakening, pain typically worse at night bc ppl sleep w flexed wrists (compress further).--Sensation at volar pads of thumb, index and middle fingers from compression. ROM normal, pain over wristTinel’s sign at wrist (light percussion over nerve to elicit tingling/pins&needles Phalen’s sign (pt push dorsal surfaces of both flexed hands together for 60sec+ if burning, tingling sensation thumb, index, middle fingerEMG gold standard &nerve conductionCR usually normal

Wrist braces/splints, US heat, ergonomics,Corticosteroid and surgical release flexor retinaculumProg: good if early detec, bad if left untreated; pain and weakness

Peripheral Neuropathy

SUMMARY: Ulnar nerve: C8/T1 radiculopathy (lower trunk)cubital tunnel at elbowguyon’s tunnel

Cubital Tunnel Syndrome

(Note: a radiculopathy would usually has neck pathology present/paraspinal)

Ulnar nerve entrapment when cross ulnar groove

Ulnar nerve (branch medial cord) compressed in cubital tunnel or in band of aponeurosis btwn proximal heads of Flexor carpi ulnaris muscle

Pain follows ulnar distribution; numb/tingling/burn/weak grip 4th and 5th digits; weak hypothenar and hand intrinsic muscles (lumbricals/interosseiTinel test +: taping nerveworse painNerve Conduction Study for dxPalpating forearm should NOT cause pain

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Guyon Tunnel syndrome

Ulnar nerve compressed w/in guyon tunnel at wrist; ulnar sideBtwn hook of hamate and pisiform

Bifurcation into superficial (sensory) and deep (motor) branch. If compression before bifur, both affected, if after bifur, only deep branch/motor deficit observed; weakness hypothenar muscles

Radial Tunnel syndrome; Posterior interosseous nerve syndrome

might not have pain, may just be weakness in extensor muscles; if do have pain, commonly confused w lateral epidonyltitis

Compression of radial nerve distal to lateral elbow/epicondyle –over supinator where divides to superificial and deep radial nerve which penetrates supinator to become post. interosseus nerve

Predominantly MOTOR neuropathyWeakness in elbow supination (but can still do bc supinator innervated deep radial nerve) and finger extension (ESP Middle finger). No weakness proximal to elbow. Dull, aching pain over lateral elbow, but otherwise no sensation ∆s.Diagnose w nerve conduction study and EMG

Hip & KneeBones-Fractures/DislocateAcetabular Fracure Less common fx;

elderly at risk bc osteoporosis

MVA or fall; Direction /magnitude of force and position femoral head determine fx pattern

Avascular Necrosis (AVN)-Femoral Head

Lack of blood 2° to trauma, diabetes, sickle cell, SLE, chronic corticosteroid use

Cellular death of bone from lack blood supply

Initially, asymptomaticAfter progression, bone collapse and hip joint destroyed

Total hip replacement

Posterior Hip Dislocation

More common than anterior

Blunt force trauma from MVA on pedestrian or fall from height

Lower extremity internally rot. & aDducted.Sciatic nerve compressed by femoral head

Femur Intertrochanteric Fx

Elderly pts; trauma, osteoporosis

different from neck fx (above trochanteric line)leg becomes shortened bc pull of gluteal muscle

Damage to circumflex femoral arterycommon post-traumatic complication of AVN of femoral head

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tendons; also Ext Rot and Abducted

Toddler Fracture 1-3YO; accidental fall after foot entrapped

mid-shaft oblique fx of tibia; spiral from twisting/torsional injury lower extremity

Swelling/warmth over fx site;Child will refuse to walk/bear weight on damaged limb; may not be visible on CR; usually purely mechanical patholgoy

Patellar Fracture Direct or indirect trauma; most common transverse fx

Jumping or eccentric contraction of quads; or fall on knee cap; trauma anterior knee

Swelling anterior knee, bruising, possible abrasionLimited ROM, inability to flex knee

If unable to do straight leg raise testsurgeryFull recoveryIf vertical fx, usually no surgery needed bc tendons pull tight

Tibial Stress Fracture

most common location stress fx;

Bone repair unable to keep up w repetitive trauma; bone damagestress fx; unbalance remodeling

Pain over medial aspect of tibia (shin splints); gradual onset painconstantPain=localized, deep ache; reproduced hopping or jumping on leg; pain after weight-bearing, pain w rest, ice, NSAIDROM knee, hip, ankle=normalMRI gold standard for dx, CR helpful

Legg Calve Perthes Disease

Idiopathic (no hx trauma) AVN of femoral head; young caucasion boys 3-12yrs

Usually unilateral, change in blood supply at head in childhoodrisk AVN from mechanical or infectious insults

Mild hip/knee pain w limpInitial: CR normalDegenerative phase: flattened femoral headRegernative phase: head re-ossifies and no longer fits normally into acetabulumROM: Int Rot and aBduction hip

Prog: good

Osgood Schlatter Disease

Knee pain in 10-15YO; pts who jump or sports

Repetitive pulling on patella’s tendon at insertion on tibia tubercle; may cause avulsion fx

Anterior knee pain w timeProminence at tubercle w assoc effusion and warmthROM normal; pts may avoid knee flexion bc pull on patella tendonTender over tendon;CR not for dx

NSAIDS, ice, limit activity that exacerbatesStretch/strenghten quads and hamsSurgery rareProg: good; resolves 1 year


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Hip OA

Femur head and acetabulum

Causes: previous fxchanges hip alignment; undiagnosed hip dysplasia; AVN fem head

-pain in groin (dull aching, throbbing, or sharp, stabbing); tender inguinal area-antalgic gait (limp)-ROM limited; esp Int Rot and Abduct-test pain w Int Rot hip (LOSE Int Rot 1st)CR: non-uniform JSN, sclerosis, ostephyte

NSAIDS, opioids (severe)Modify lifestyle, PT strengthen muscles across hip jointCorticosteroid injectPROG: fair/poor

Developmental hip Dysplasia

Uni- or bilateral; genetic link2x more girls

Unbalanced fit femoral head & acetabulumposterior subluxation fem head

Dx: physical newborn infants; asymmetry gluteal region, thigh, labial foldsROM: limited AbductOrtolani & Barlow Maneuver: + if click or dislocate infant hip when aBduct w anterior pressureCR conclusive (red arrow), acetabulum is shallow, not really carved out.

No meds, Pavlik harness (prevent ADDuct and Extension) Brace is to do aBduct and carve out “cup”If late dx; req traction and surgeryProg: Fair; if early dx (1st

wks postnatal) then reverse condition; if no treatpt gets OA early

Slipped Capital Femoral Epiphysis

During teen, plane of growth plate femoral head changes orientation to be in alignment w direction weight bearing forces; 11-16YO white boys

Orientation change subjects growth plate to greater disruptive shearing forces from activities; mechanical stress and hormonal imbalance in pubertyrisk for displaced, Salter Harris Type I fx of epiphyseal plate fem head; shifts head of femor. Can be Uni- or bilateral; “ice cream falling off cone”

Pain: sharp/severe in groin after injury; radiate to butt and knee; w hip movement and weight bearingLeg is Ext Rot and limpingROM: Int Rot and AbductCR conclusiveRare to have AVN bc ped femoral head good circulation from ligamentum teres (which lessens in adults)

NSAIDS, strength training after surgeryscrew; surgical pinning.PROG: FairMost pts functional after surgey; but risk for early OA

Toxic Synovitis Boys 3-7YO Unknown cause aka Transient Synovitis bc transient clinical presentation; ACUTE onset, overnight

Acute pain, limp for 3-5 days; palpation does NOT produce pain; joint effusion cause femur to pop out of socket and uncomfortableROM: limited Int Rot from painPresents commonly in morning; pt typically NOT sickCBC and ESR normal, CR normal

NSAIDS, restPROG: good, resolves on own

Knee OA >55YO or younger Medial compartment (most -Bilateral; dominant pain one side; limp; -NSAIDS opioids

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if hx trauma; assoc w other problems (meniscus or ligament tear, prior fx), obesity

common, but all 3 possible (lateral and patellofemoral)-“bow-legged” from degen of medial femorotibial articulation-varus: distal bone points toward midline-valgus (“knock-kneed”) distal bone points away from midline of body

tender over joint-gradual, intermittent painconstant; w weightbearing activities, rest-knee stiffness, esp after activity-ROM: restricted flex/extend, pain at end of ROM; crepitus palpated w ROMCR: marginal osteophytes, sclerosis, non-uniform JSN

-Lifestyle modification: exercise, PT and weight-brace (stability), cane opposite side (off load weight), shoe wedges (correct varus or valgus)corticosteroid inject (pain/inflamm), eventual total knee replacePROG: fair to poor

Patellofemoral Syndome

Knee pain young


Overuse, overload, muscle or biomechanical problem of patellofemoral joint; loss of smooth patella gliding over femoral condylesgrinding retropatellar surface on femur;ROM: limited knee flexion

Gradual onset anterior knee pain due to repetitive movement patella over femur; tender lateral aspect patella w palpate-dull ache, swelling, “click” of patella/crepitus; follow tracking patellapain climbing stairs, walk, run, prolonged sitting and standing from seat; pain w rest.Assoc. w strength quads, offset patella, swollen knee jointAtrophy vastus medialis muscleCR normal

NSAIDSRest, cold, brace/tape, strengthen quadsLast resort surgeyPROG: good

Tibial Torsion Genetics or positioning of leg in uterus; self corrected rotation by age 2 via walking

During development after birth, tibia turns in or out“toeing-in/pigeon toe” =Internal torsion; ankle &foot also turn

NO pain“toeing-in gait”, occasional trippingROM: normalCan measure angle between thight and foot (normal is w/in 10deg)No need CR

Observation, potential night time splint to help correctSurgery req if do not resolvePROG: good

Muscles/TendonsTrochanteric Bursitis

Runnersacute, repetitive trauma

Painful inflamm of bursa btwn greater trochanter and insertion gluteus maximus tendon; IT (iliotibial band; thickening of facia lata) becomes tightpressure on bursaStretching IT band

Gradual, pain lateral hip, swellingDeep ache constant deep painpain pressure on lateral hip, walking, running; palpate pain IT band and greater trochanter;ROM: normal; CR normalNOTE: If have referred groin and knee pain w passive Int Rot of hip

NSAIDs, rest, ice (acute)PT: stretch IT band (picsChronic: deep heat (US)Assess gait abnormalities and address w assistive devices (ex. Cane)Corticosteroid inject into

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reproduce pain jointmore likely hip joint path (ex OA) and not this

bursaPROG: good

Pes Anserine Bursitis

Irritation/inflamm of pes anserine bursa at medial kneePes anserine (common tendon gracilis, Sartorius, semitendinosus)

Tender palpate over bursa, but NOT over joint line or patella; may reproduce pain w passive knee extensionMild swelling or normal at medial knee below joint lineROM: normalCR: normal

NSAIDSIce, lower extremity stretchingCorticosteroid injectProg: Good

Meniscal Tear Crescent shaped medial and latereal menisci; provide shock absorption. Tear when foot is planted and knee twisting (common football, bball, skiing)If medial meniscus is injured, risk tear of MCL since its attached to medial meniscus

Acute injurymild swelling, pain >24hrsIf degen changes cause teargradual onset pain, w timeMild to mod pain, dull ache; but SHARP w twist or bend“popping, clicking, catching” assoc. w joint effusion; locking/pain w squatROM: limited extend, pain w full flexionEffusion/tenderness at joint lineMcMurray test: meniscal tearperform on ACL, PCL, MCL, LCL to rule out add’l lig injury

NSAIDsInitally: activity, ice, crutches if severe painLater: quads and hams muscle strengthening exercisesSurgery if ACL tear also or “locking” from flap of meniscus getting caughtProg: good to fair depending on severity; risk OA

Knee Ligament Tear 4 ligs:ACL: prevent ant. translation of tibiaPCL: prevent post. translation of tibiaMCL: medial knee stabilityLCL: lateral knee stability

ACL tear: MOST COMMON from high impact jumping, twisting, impact on lateral side knee while foot planted; audible “pop”, swelling 1hrPCL tear: “dashboard” injurieshit tibia from front while bent knee and pushes it backMCL tear: excessive valgusLCL tear: excessive varus“unhappy triad/terrible triad injury”=MCL, ACL,

IMMEDIATE pain following maneuver; initially sharp/severe and softens to dull ache, ACLACUTE swellingpain/instability w strenuous, hard-impact activities (climb, run, jump); knee “gives out”hemiarthrosis, effusionROM: limited flex & extendACL tear: Lachman and anterior drawer test; blood in jointPCL tear: posterior drawer testValgus (for MCL) and varus stretch (for LCL ) laxityMRI gold standard for ligaments

NSAIDS, icePT: proprioception training, ROM exercises, quads and ham strengthening to stability; use braceSurgical reconstruction (grafts or cadaver) for ACL tearPROG: Good: pts w PCL, MCL, LCLFair: untreated ACLknee instabilityrisk degen

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medial meniscus tears; clipping injury (

NERVES/VESSELSCompartment Syndrome

Limb and life threatening;Common lower limb

Perfusion pressure drops below tissue pressure in closed anatomic space; compartment pressure builds from swelling (trauma, tight casts, etc) or bleeding.tissue necrosis, permanent func impairment, rhabdomyolysis (excessive tissue damage) that can progress to renal failure/death

Acute onset following injuryChronic: repeated low intensity traumarecurrent and progressive painSUSPECT whenever significant pain occurs in extremity following an injurypain w movement, nerve impairment cause severe pain/burningnothing painextremity: swollen, w or w/o pallor; may feel warm or cold, eventually tenses/hardens as if filling w fluidpain passive stretching of musclesCR not dx

IV hydrationO2 given bc ischemic injury; hyperbaric O2 if availableDo NOT elevate extremity-will worsen ischemiaFasciotomy-cut fasciaPROG: Good if fasciotomy done w/in 6 hrsPoor: necrosis occurs >6hrs

Peripheral NeuropathiesLateral Femoral Cutaneous Nerve Syndrome

Compressed nerve at lateral edge of inguinal ligament

Burning, numbness, parestheia down proximal-lateral thigh

Piriformis Syndome Sciatic nerve enters gluteal region via greater sciatic foramen deep to piriformis

If piriformis tightenscompresses sciatic nerve

Pain referred to gluteal region and posterior thigh compartment, “deep pain”

Common Peroneal Nerve Entrapment

MOST common peripheral nerve injury lower extremity

Injured any locations along thigh to fibular head (trauma, laceration, femoral fracture, bullet wound)MOST injury at fibular head;

Nerve wraps around fibular head and can be compressed here; can get compressed from habitual leg crossing, or compression against bed railing or hard mattress for debilitated pt or prolonged immobility (seen w pts under anesthesia)


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Lateral Malleolar Fx Fx distal fibular; ankle fx

Direct trauma or twisting injury assoc. w ligament injuries on medial side(widening of joint); thus search for multiple injuries

Bone tenderness at posterior edge and tip of lateral malleolusInability to bear weight

Medial Malleolar Fx Fx distal tibia; ankle fx

Landing from jump or rolling ankle; large traumatic force req such that other injuries involved-->torn deltoid lig

Sudden onset sharp, intense ankle painWalk w limp

5th Metatarsal Fx; Jone’s Fx

Forceful inversion of foot concurrent w contraction of peroneus brevis muscle

Avulsion fx of base of 5th metatarsal bone; transverse or oblique fx

Pain and tenderness at base 5th metatarsalLocal bruising and swelling

Non-displaced fx treated conservatively; surgery for comminuted or displaced or non-union

Calcaneus Fracture High-energy injury; fall from height; MVA, sports Initial

2weeks later

Swelling, pain over calcaneus and heel painSubtalar Joint: btwn calcaneus and talus; when calcaneus fx, lose inversion/eversion of footTypically no effect on dorsi/plantar flex

risk OA at subtalar jointsurgery

JOINTSGOUT Common inflamm

monoarthritis; deposition monosodium urate monohydrate crystals in joint & periarticular tissues; humans non-func uricase

Serum urate >6.8mg/dL (hyperuricemia)Men>40YOUncommon premenopause womengout w obesity ratesEtoHgouty flares in younger ppl`25% 1st attacks will not reccur in ppl1st MTP jointpodagra; but any joint susceptible

Asymptomatic hyperuricemia: relatively commonAcute gouty arthritis: MSUM crytsals ppt an inflamm response; rapid warmth, erythema, swelling soft tissue, joint effusion, pain at rest, active, and passive ROM; may also get tenosynovitisperiarticular pain/swelling.pain over 8-12hr periodattacks over time can involve more joints, be more frequent, and longer duration

2 phases:1) control inflammation (colchicine, NSAIDS, systemic steroids, intraarticular steroid injections)2) lower serum uric acid level (intake organ and red meats, shellfiss and high purine diet; also consider medsPROG: good to fair

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hematology: serum uric acid level is not indicative and normal does not rule out; many ppl no gout, but serum uricsynovial fluid: needle shape crystals, negatively birefringent (blue perpendicular)Radiology: takes years b4 develop; erosions w punched out appearance and sclerotic margin/overhangind edges

MUSCLES/TENDONSAnkle Sprain Most common is

lateral sprainInversion (twising in and upward) of foot; rolling ankle inwardAnterior talofibular ligament

Diffuse pain initially, then localize to lateral aspect (ATF lig) or medial aspect (deltoid lig) as swellingAcute pain from trauma; initially sharpdeep achepain w weight being and ROM; w restif severelocal swelling/bruisingROM: active and passive painfulPalpate medial and lateral malleolus; base 5th metatarsal and mid-foot bones. Should NOT have bony point tenderness (indicates possible fx then)CR normal

NSAIDSPRICE for acuteBraces/tape for protectionGradually progress back to physical activitiesSurgery for severe sprainsPROG: good: mild sprainFair: mod-severe lateral, medial ankle sprain and “high” ankle sprain

Plantar Fasciitis “jogger’s heel”, “tennis heel” “policeman’s heel”

Overuse of plantar fascia at its attachment to calcaneus bone from activities of max plantar flexion of ankle and dorsiflexion of MTP joints

Gradual onset inferior heel pain after change in activity level, shoe, or surfacePain w/ 1st few step in morning or periods non-weight bearingpain w stretching plantar fascia, walk bare foot, or upstairsAssess gait and shoesROM: ankle dorsiflexion may be limited from tight Achilles tendonpoint tenderness at medial process of calcaneal tuberosityCR: calcaneal spurs from chronic pulling via plantar fascia

NSAIDSPRICE, PT, strengthen gastroc-soleus complex, massage w friction.Orthotic devices to cushion heal and arch support, night splints, weight loss, modify activityCorticosteroid injectionSurgery (fascial release or debridement)PROG: good (80% cases resolve spontaneuously w/in 1yr

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Achilles Rupture 30-50YO, 4-5cm proximal to calcaneus bone where poor blood flow to tendon

sudden strain or direct blow to tendon while

contractedDisruption of Achilles tendon

Acute onset pain; “shot, kicked or cut” in back of leg; swelling, instant weaknessInability to walkpain w weight bearing and palpation of calf; pain w restROM: weak/absent plantar flexionPalpable defect in tendonThompson Test: pt lying prone w knee passively flexed, dr squeeze calf and loo for foot plantar flexion. + test if plantar flexion ablestCR not needed

NSAIDSPRICE, PT for post-op and post-cast care, isometric ankle and progressive resistance exercises, proprioceptive trainingSurgical repair high level athletes or if medical therapy (crutch, non-weight bearing, casting, orthrotics) FAILPROG: good; but lose some ROM

NERVES/VESSELSTarsal Tunnel Syndrome

Most common entrapment neuropathy of foot/ankle

Compression tibial nerve posterior to medial malleolus where travel under flexor retinaculum in tarsal tunnel

Paretheses of plantar foot, posterior leg numbness, plantar flexion weakness, and clawing of toes

Interdigital Neuritis AKA Morton’s neuroma; irritated when where high heels; squeezing metatarsal heads together

Entrapment of plantar interdigital nerve as passes under transverse metatarsal lig;

As weight transfer to ball of foot when toes dorsiflexed during push off of gait, nerve is compressed between plantar foot and distal edge of lig

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Special Testing1. Spurling’s Compression Test

a. Positive for cervical radiculopathy 2. EMG

a. Detecting particular nerve damage b. Helps locate a particular nerve that’s

involved3. Leg Length Test

a. Sacroiliac Joint Dysfunction 4. Faber Test

a. Sacroiliac Joint Dysfunction b.

5. Straight Leg Raise Test a. Lumbar Radiculopathy

6. Babinski’s Sign a. Testing for spinal cord injury due to spinal

cord compression b. Foot dorsiflexes and big toe extends when

rubbing the lateral side of the foot is positive for neurological damage.

7. Sulcus signa. Shoulder Instability b. Downward traction of humerus can see a

depression below the acromion8. Hawkin’s Sign

a. Shoulder Impingementb. Shoulder abducted 90 deg and elbow flexed

90 deg, internally rotate humerus, positive if pain is ilicited

9. Neer’s Signa. Shoulder Impingement b. Max passive abduction in scapula plane with

internal rotation while stabilizing scapula will cause pain in the sub acr. Bersa or anterior edge of acromion

10. Resisted Wrist Flexion a. Medial epicondylitis

11. Resisted Wrist Extension a. Lateral epicondylitis

12. Finkelstein’s Testa. DeQuervain Tenosynovitisb. Cup thumb in fingers and ulnar deviate

positive if it ilicits pain 13. Tinel’s Sign at wrist

a. Carpal Tunnel (median nerve compression)b. Percuss median nerve at wrist

14. Phalen’s Testa. Carpal Tunnel (median nerve compression)b. Push back of hands together for 1 minc. Positive if it causes same symptoms

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Table 1. Cervical Radiculopathy

Table 2. Lumbar Radiculopathy.