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Advanced Health Assessment- Musculoskeletal
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Terms in this set (263)
Approximately 85% of patients have _______ pain (this term is preferred to "sprain" or "strain"). From msuculoligamentous injuries, age-related degenerative processes of the intervertebral discs and facet joints
idiopathic low back
For midline back pain, you should assess for?
musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metastases, or rarely epidural abscess.
For pain off the midline, you should asses assess
for muscle strain, sacroiliitis, trochanteric bursitis, sciatica, and hip arthritis, also for renal conditions like pyelonephritis or kidney stones
Radicular gluteal and posterior leg pain in the S1 distribution that increases with cough or Valsalva is called ______. Leg pain that resolves with rest and/or lumbar forward flexion in __________.
Sciatica/ Spinal stenosis
"Red Flags" when pt has complaint of back pain
Age >50 y/o, bowel or bladder dysfunction, hx of cancer, idiopathic weight loss, pain >1 mo, no response to tx >1 mo, pain at night, increased pain w/rest, hx of IV drug use, presence of infection. These all indicate an underlying systemic disease.
In cases of low back pain plus a red flag, there is a 10% probability of
serious systemic disease.
Cauda equine syndrome
Presence of bowel or bladder dysfunction (especially urinary retention or overflow incontinence)
Radicular pain from spinal nerve compression, most commonly C7 followed by C6. Unlike low back pain, usually from?
foraminal impingement from degenerative joint changes
Pain in one joint suggests:
Trauma, monoaricular arthritis, possible tendinitis or bursitis
Lateral hip pain near greater trochanter suggests what?
A migratory pattern of spreading joint pain suggests what?
Rheumatic fever or gonococcal arthritis
A progressive, additive pattern of joint pain with symmetry suggests what disease?
Extra-articular pain examples:
Inflammation of bursae (bursitis), tendonitis, tenosynovitis, sprains (stretching or associated tearing of ligaments)
Rapid onset of severe pain associated with redness and localized edema suggest what?
Acute septic arthritis or gout. In children concern for osteomyelitis if near a joint
Joint pain + fever, chills, warmth & redness suggests what?
Septic arthritis. Also gout or rheumatic fever.
Pain, swelling. Loss of active and passive ROM, "locking,"
Articular joint pain
Loss of active but not passive ROM, tenderness outside of the joint space
Stiffness and limited motion after inactivity, "gelling", usually only lacking a few minutes, is found of what disease
Degenerative joint disease
Stiffness lasting 30+ minutes suggests what?
Rheumatorid arthritis and other inflammatory arthritides. Also, fibromyalgia and polymyalgia rheumatica (PMR)
Generalized symptoms such as fever, chills, rash, anorexia, weakness are common findings of what?
Rheumatoid arthritis, systemic lupus erythematous (SLE), Polymyalgia rheumatica and other inflammatory arthritides.
High fever and chills associated w/joint pain suggests what?
Butterfly rash on cheeks
Systemic lupus erythematosus
Scaly rash w/ silvery plaques and pitting nails
Few papules, pustule or vesicles on reddened bases located on the distal extremities is associated w/what musculoskeletal condition?
Expanding erythematous patch early in an illness w/ associated joint pain is suggestive of what?
Urticaria associated to arthralgias suggests
Serum sickness or drug reaction
Erosions or scale on the penis and crusted, scaling papules on the soles and palms with arthralgias suggests what?
Reiter's syndrome. Includes arthritis, urethritis and uveitis
A maculopapular rash of rubella with joint pain
Arthritis of rubella
Clubbing of fingernails w/arthralgias
Red, burining, ichy eyes with associated joint pain suggests:
Reiter's syndrome, Bechet's Syndrome
A preceding sore throat to arthralgias suggests
Acute rheumatic fever or gonococcal arthritis
Arthritis + diarrhea, abd pain and cramping suggests
Arthritis w/ulcerative colitis, regional enteritis, scleroderma
Arthritis, mental status change, facial weakness or other areas of weakness, stiff neck are concerning for what?
Lyme disease w/CNS involvement
Subcutaneous nodules are characteristic of what?
Rheumatoid arthritis, rheumatic fever, effusions due to trauma, inflamed tendon sheath of tenosynovitis; crepitus over inflamed joints (osteoarthritis)
Palpable bogginess or doughiness of the synovial membrane indicates
Synovitis, may be accompanied by effusion
Decreased range of motion caused by
arthritis, inflammation of tissues around a joint, fibrosis in or around a joint or bony fixation
Localized warmth near a joint is concerning for what conditions
Arthritis, tendinitis, bursitis, osteomyelitis, other infection
Swelling at the subacromial and/or subdeltoid bursae suggest what?
Muscular atrophy or weakness seen in
Tenderness over the rotator cuff insertion site w/inability to abduct the arm is seen in?
Sprains, tear, tendon ruptures of the rotator cuff muscles. Most commonly injured is supraspinatus.
Best predictors of rotator cuff tears can be seen in what examination?
Weakness with resisted Abduction (supraspinatus), infraspinatus weakness during external roattion and positive impingement sign (Neer's test, hawkin's test).
63 y/o male with shoulder pain and +dropped- arm test and weakness with shoulder aBduction. What is your diagnosis
Rotator cuff tear (partial vs. full thickness)
Localized tenderness of pain at the AC joint with aDDuction (crossover test) suggests what?
Inflammation or arthritis of the acromioclavicular joint. However, these tests are not very specific
Positive Neer's test suggests what?
Rotator cuff etiology (i.e. tear) for shoulder pain. Neer's impingement sign is when you passively raise the pt's arm above their head while stabilizing the scapula in your other hand. This compresses the humerus against the acromion
Hawkins impingement sign
Flex the pt's shoulder to 90 degrees, palm facing down. Then rotate the elbow internally by pushing upward while supporting the forearm w/your other hand. This causes compression of the greater tuberosity against coracoacromial ligament.
Positive Hawkins impingement sign indicates what
Shoulder pain of rotator cuff tear etiology
Weakness during infraspinatus strength testing (resisted abduction of shoulder joint w/arms flexed at 90 degrees) indicates what?
Rotator cuff tear of bicipital tendinitis.
Pain with resisted forearm supination indicates what?
Inflammation of the long head of the biceps tendon, possible rotator cuff tear
What is drop arm sign and what does it mean?
Test: ask pt to fully abduct arm to 90 degrees then lower it slowly. If pt cannot hold arm fully abducted the test is positive and indicates rotator cuff tear.
The olecranon is displaced posteriorly in
posterior dislocation of the elbow and supracondylar fracture.
If pt is able to fully extend the elbow what conditions are unlikely
fracture, intra-articular effusion, and hemarthrosis
Heberden's nodes at the DIP joints, Bouchard's nodes at the PIP joints suggest
Symmetric deformity in the PIP, MCP, wrist joints with ulnar deviation
Hypothenar atrophy is indicative of what nerve damage?
What nerve is damaged in thenar atrophy?
Median (median recurrent branch here) caused by ulnar nerve compression
Flexion contracture in the ring, pinky and middle fingers arise from thickening of the palmar fascia.
Tenderness over the distal radius with step-off s/p fall, especially in patients with osteoporosis is indicative of what type of fx?
Tenderness over the extensor and abduction of the thumb the radial styloid suggest
deQuervain's tenosynovitis or gonococcal tenosynovitis
Tenderness over the snuffbox?
Scaphoid fracture. Risky because of avascular necrosis, due to poor blood supply. Most common injury of the carpal bone.
Pain with pressure at the MCP joints, as in shaking hands suggests what
Synovitis of the MCPs, post-traumatic arthritis, rheumatoid arthritis. or Posttraumatic arthritis -osteoathritis not common
carpometacarpal arthritis has pain where?
Base of the thumb.
Hard, dorsolateral nodules (Heberden's nodes) on the
DIP joints- these are also involved in psoriatic arthritis
nodules on the DIP joints are known as?
Heberden's nodes, common of OA
Conditions that impair range of motion in the hand include..?
arthritis, tenosynovitis, Dupuytren's contracture.
Risk factor for carpal tunnel syndrome
Repetitive motion with wrists flexed (typing, mail-sorting), pregnany, RA, diabetes, hypothyroidism. Thenar atrophy may also be present.
Decreased grip strength can be seen in what disorders?
Weakness of the intrinsic hand muscles or forearm flexors, de Quervain's tenosynovitis, arthritis, carpal tunnel, epicondylitis, cervical radiculopahty
Finkelstein's test, asking the patient to grasp the thumb against the palm and then move the wiriest toward the midline (ulnar deviation) is for what?
De Quervain's tenosynovitis, from inflammation of the abductor politic longs and extensor policies brevis tendons and tendon sheaths.
Tests for carpal tunnel syndrome
Thumb abduction (weakness=positive), Tinel's test (aching and numbness= positive) Phalen's test (numbness and tingling within 60 seconds= positive)
Contraction of the sternocleidomastoid muscle causing lateral deviation and rotation of the head
Spinous process tenderness is concerning for?
Fracture or dislocation if preceded by trauma or underlying infection or arthritis
Describe a positive Phalen's test
Numbness and tingling on the median nerve digits (middle, index, thumb) within 60 seconds is a positive test.
During palpation of the spine, tenderness is felt at the facet joints between C5 and C6. What is the top of your differential?
Step offs of the spinous process indicate what?
Foward slippage, subluxation, spondylolisthesis, infection
On physical exam, a 29 y/o male is found to have tenderness over the sacroiliac region. What are you concerned for?
Sacroiliitis or ankylosing spondylitis
What could cause unequal shoulder heights (think of posterior view)?
Scoliosis, Sprengels deformity of scapula, winged scapula secondary long thoracic damage innervating serratus anterior, contralateral weakness of trapezius muscles, Anteriorly consider clavical fx (drop shoulder) or glenohumeral dislocation
"Listing" of the trunk to one side indicates
Herniated lumbar disc
Signs of spina bifida
Birthmarks, port-wine stains, hairy patches and lipomas over the bony defect
List some signs of neurofibromatosis
Café-au-lait spots, skin tags, fibrous tumors
At which level is a herniated disc most likely to occur (name 2 levels)?
L5-S1 or L4-L5. Look for tenderness of the spinous process, intervertebral joints, paravertebral muscles, sacrosciatic notch, sciatic nerve
Deformity of the thorax on forward bending
What spinal finding would you expect with muscle spasm, flexion deformity of the hip or ankylosing spondylitis?
Persistence of lumbar lordosis
Considering a large width of a gait what are you concerned for?
Wide base suggests cerebellar disease or foot problems. Abductor weakness, hip dislocation or arthritis can also cause contralateral hip drop that results in a waddling gait
Leg shortening and external rotation suggests?
Name the relationship of nerve, artery, vein and lymph node through the inguinal triangle starting laterally -medially
N.erve, A.rtery, V.ein, E.mpty space (canal for femoral hernias), L.ymph node (NAVEL)
Pt with focal tenderness over the greater trochanter
Trochanteric bursitis. Also tendonitis or muscle spasm from referred hip pain, iliotibial band tendinitis (posterolateral tenderness)
A hip flexion deformity may be masked by what?
An increase in lumbar lordosis or an anterior pelvic tilt. For the hip flexion exam the natural lumbar lordosis should flatten out on the table and thigh should almost touch chest.
Sacroiliac joint tenderness
swelling over the patella suggests _____ vs swelling over the tibial tubercle which suggests _____
Over patella: prepatellar bursitis; over tibial tubercle: infrapatellar or anserine bursitits
What type of knee tear is common after trauma
medial meniscus tear
tenderness over the tendon or inability to extend the knee suggests
a partial or complete tear of the patellar tendon
Pain with compression and with patellar movement during quadriceps contraction suggests
Chondromalacia or degenerative patella (patellofemoral syndrome)
Thickening, bogginess or warmth of the suprapatellar pouch, prepatellar bursa and anserine bursa suggests
Synovitis or non-tender effusion from osteoarthritis
Name risky behaviors/repetitive movements for these conditions: Prepatellar bursitis, Anserine bursitis
Prepatellar bursitis ("housemaid's knee") from excessive kneeling. Anserine bursitis from running,
valgus knee deformity, fibromyalgias, osteoarthritis. Also, a popliteal or "baker's" cyst from distention of
the gastrocnemius semi-membranosus bursa from underlying arthritis or trauma
Tenderness over posterior lower leg with swelling, and absence of plantar flexion, with a flat footed gait suggests
ruptured achilles tendon
A fluid wave or bulge on the medial side between the patella and the femur is considered a positive bulge sign consistent with
The bulge (fingers at medial patella) and "balloon sign" (fingers grasp both sides of the patella) are tests for what?
Knee joint effusion
A click or pop along the medial joint with valgus stress, external rotation, and leg extension uggests
Medial meniscus tear, along the posterior border
Locking of the knee with full extension might occur as a result of what ligamentous injury?
A medial meniscus tear, along posterior portion causing displaced meniscal tissue
Positive McMurray sign and locking of the knee indicates
Medial meniscus tear
Most knee injuries occur medially or laterally?
Anterior drawer sign is testing the integrity of what structure?
Anterior cruciate ligament
Forward excursion on Lachman's test indicates what injury?
ACL tear 17x more likely if the test is positive
A forward jerk that shows the contours of the upper tibia is a positive what sign and what does it indicate?
Anterior drawer sign, ACL tear
Compress the forefoot between the thumb and fingers, tenderness here suggests
Early sign of RA
Palpate the heads of the five metatarsals and the grooves between them with your thumb and index finger, pain here indicates?
Metatarsalgia from trauma, arthritis or vascular compromise
Tenderness over the 3rd and 4th metatarsal heads on the plantar surface
Right knee with moderate effusion and tenderness over the medial meniscus along the joint line. Moderate laxity of ACL on anterior drawer test, extension intact, MCL and LCL intact. What does this exam indicate?
Partial tear of the medial meniscus and ACL
Mechanical Neck pain
Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, with associated stiffness and tightness in the upper back and shoulder, lasting up to 6 weeks. No associated radiation, paresthesias, or weakness. Headache may be present.
Nocturnal back pain, unrelieved by rest
consider metastatic malignancy to the spine from cancer of the prostate, breast, lung, thyroid, and kidney. Loss of normal lordosis, muscle spasms, and limited anterior and lateral flexion.
Mechanical Neck pain-Whiplash
neck pain with aching paracervical pain and stiffness, often beginning the day after injury. Occipital headache, dizziness, malaise, and fatigue may be present. Chronic whiplash syndrome if symptoms last more than 6 months, present in 20% to 40% of injuries.
Sharp burning or tingling pain in the neck and one arm, with associated parathesias and weakness
Cervical Radiculopathy—from nerve root compression
Degeneration and progressive loss of cartilage within the joints, damage to underlying bone, and formation of new bone at the margins of the cartilage
An inflammatory reaction to microcrystals of sodium urate
Gouty arthritis, acute gout
Multiple local accumulations of sodium urate in the joints and other tissues (tophi), with or without inflammation
Chronic tophaceous gout
Sudden onset of pain in the muscles of the hip, neck, and shoulder girdle; symmetric, "gelling" >50y/o. Prominent stiffness in the morning.
Widespread pain and tender points. Shifts unpredictable or worsens in response to immobility, excessive use, or exposure to cold. "all over pain"
DDx for swollen or tender elbows?
Olecranon bursitis, arthritis, rheumatoid nodules, epicondylitis
Osteoarthritis ir more common in
Women, especially in the knee
swelling and tenderness of the entire joint, that limits both active and passive range of motion due to stiffness or to pain, is what type of disease?
disease involving selected regions of the joint and types of movement, is called what?
Leukemia can infiltrate the? chemotherapy can cause?
Peak bone mass is reached by age?
Bone less due to age related declines in ____ is initially rapid then becomes slow
30, estrogen and testosterone
Osteoporosis is common in
hepatic and renal disease
Rhematoid arthritis is typically
polyarticular and symmetrical
after trauma, ACL tear
Redness over a tender joint suggests?
septic or gouty arthritis or possibly rheumatoid arthritis.
Facial asymmetry, tenderness, unilateral chronic pain with chewing, jaw clenching or teeth grinding, often with headache is seen in
Pain with chewing occurs in
trigeminal neuralgia, temporal arteritis, TMJ
Palpable crepitus or clicking is present in TMJ suggesting?
poor occlusion, meniscus injury or synovial swelling form trauma
elevation of one shoulder is seen in
rounded lateral aspect of the shoulder appears flattened with
anterior dislocation of the shoulder
atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear 2-3 weeks after
rotator cuff tear
______ amount of fluid is needed before the glenohumeral joint capsule appears distended. swelling of the AC join is (easier or harder) to identify.
Localized tenderness of subacromial and sub deltoid bursae suggests
bursitis, degenerative changes, calcific deposits in the rotator cuff.
Difficulty with internal and external rotation suggests
rotator cuff disorder or adhesive capsulitis
swelling over olcecranon process is found in
olcecranon bursitis, inflammation of synovial fluid occurs in arthritis.
Tenderness distal to the epicondyle is common in _____ and less common in ______ (elbow)
lateral epicondylitis (tennis elbow) , less common in medial epicondylitis (pitcher's or golfer's elbow)
Diffuse Swelling indicates ________ Localized swelling indicates _______? hand
arthritis or infection/ ganglion
Decreased sensation in the median nerve distribution characterizes?
carpal tunnel syndrome.
Neck stiffness signals?
arthritis, muscle strain, or other underlying pathology that should be pursued. HA may be present.
Thoracic kyphosis increases with?
Pain on percussion of the spine may arise from
osteoporosis, infection, or malignancy.
Unequal heights of the iliac crests or pelvic tilt suggests
unequal lengths of legs, Scoliosis and hip abduction/adduction can also cause a pelvic tilt.
spinal muscle spasm occurs in?
degenerative and inflammatory processes of muscles overuse, prolonged contraction from abnormal posture or anxiety.
Sciatic nerve tenderness suggests:
a herniated disc or mass lesion impinging on the contributing nerve roots. this nerve is difficult to palpate in most patients.
Limitations in ROM of the neck can arise from
arthritis, pain from trauma, overuse, or muscle spasm such as torticollis.
Tenderness at C1-C2 is seen in
rheumatoid arthritis, suggests possible risk for subluxation and high cervical cord compression and needs prompt additional assessment.
Lack of knee flexion, which makes the leg functionally longer interrupts what?
interrupts the smooth pattern of gait with circumduction of the extremity or swinging the leg out to the side.
Loss of lordosis may reflect _________, excess lordosis suggests __________ or the hip
para-vertebral spasm/ flexion deformity
Changes in leg length are seen in?
Adduction or abduction deformities and scoliosis.
Bulges along the inguinal ligament suggests
inguinal hernia or occasionally an aneurysm
Tenderness in groin area may be from
synovitis of the hip joint, arthritis, bursitis, or possibly psoas abscess.
tenderness in ischiogluteal bursitis
"weaver's bottom" because of the adjacent sciatic nerve, this may mimic sciatica.
Stumbling or "giving way" of the knee during heel strike suggests
quadriceps weakness, or abnormal patellar tracking
Bowlegs- proper name
Knock knee- proper name
Genu varum/ Genu valgum
Thickening of the tendon above the calcaneus, sometimes with a protuberant posterolateral bony process of the calcaneus suggests
Pain or gap in the joint line points to ligamentous laxity and a partial tear of the ______ depending on location on the knee
Medial collateral ligament/lateral collateral ligaments- depending on if the gap is at the medial/lateral joint line
Hyperextension and direct blow to the knee, twisting or landing on an extended hip or knee causes what injury?
Focal heel tenderness on palpation of the plantar fascia suggest ________ seen in prolonged standing for heel-strike exercises
plantar fasciitis, also seen in RA and gout.
Tenderness along the posterior medial malleolus suggest? and causes flat feet
Posterior tibial tendinitis
After trauma, inability to bear weight after four steps and tenderness over the posterior aspects of either malleolus, especially the medial malleolus is suspicious for
ankle factor, known as Ottawa ankle rule.
Acute inflammation of the first metatarsophalangeal joint suggests
Arthritic join is frequently painful when moved in _________, whereas a ligamentous sprain produces maximal pain when the ligament is _________.
any direction/ stretched.
Forefoot abnormalities like hallux valgus, metatarsalgia, and morton's neuroma are more common in:
women who wear high-heeled shoes with narrow toe boxes.
Synovial Joints Types: Spheroidal (Condylar)
Convex or concave
Movement of two articulating surfaces not dissociable
Knee; temporomandibular joint
Synovial Joints Types: Spheroidal (Hinge)
Motion in one plane; flexion, extension
Interphalangeal joints of handand foot; elbow
Synovial Joints Types: Spheroidal (ball and socket)
Convex surface in concave cavity
Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
Bony fixation decreasing ROM
Diffuse tenderness and warmth over a thickened synovium suggest?
arthritis or infection
focal tenderness Suggest?
TMJ swelling, tenderness, decreased ROM is seen in
Inflammation or arthritis
TMJ dislocation is comonly secondary to
On palpation TMJ syndrome causes _________ and _______
Pain and tenderness
Localized Tenderness of shoulder occurs in
subacromion or subdeltoid bursitis, degenerative changes calcification deposits
Tenderness and effusion of shoulder joint suggest
synovitis - If capsule is palpable moderate effusion is present
Restrited range of motion of shoulder occurs in
bursitis, capsulitis, rotator cuff tears, sprains, tendinitis
olecranon is displaced posteriorly
Tenderness over the lateral epicondyle (epicondylitis)
Tenderness over the medial epicondyle ( epicondylitis)
Swelling over the olecranon suggests
inflammation or synovial fluid of olecranon occurs in
Guarding movement at the hands suggest
Abnormal finger alignment suggest
flexor tendon damage
Hands- Diffused swelling common in
hands- localized swelling suggest
RA affects which joint of the hand most commonly
T/F most hip problems occur during weight bearing stance phase
Body ridges tenderness along joint margins, genu varum deformity, and stiffness lasting 30 min or less and crepitus suggests
Stumbling or giving away of knee suggest?
quadriceps weakness, or abnormal patellar tracking
Flexor contracture (cant extent knee fully) suggest
paralysis, or hamstring thightness
Pain with compression over the knee along with patellar movement during quats contraction suggest
chondromalacia or degenerative changes -patellofemoral syndrome
Mechanical Low Back Pain Physical findings
Paraspinal muscle or facet tenderness, pain with back movement, loss of normal lumbar lordosis, but no motor or sensory loss or reflex abnormalities.
Mechanical Low Back Pain Physical findings in osteoarthrosis
check for thoracic kyphosis, percussion tenderness over a spinous process, or fractures in thethoracic spine or hip
Mechanical Low Back Pain pattern
Aching pain in the lumbosacral area; may
radiate into lower leg, especially along L5
(lateral leg) or S1 (posterior leg)
dermatomes. Refers to anatomic or
functional abnormality in absence of
neoplastic, infectious, or inflammatory
Sciatica (Radicular Low Back Pain)
Shooting pain below the knee, commonly
into the lateral leg (L5) or posterior calf
(S1); accompanies low back pain, paresthesias and
weakness. Bending, sneezing, coughing, straining during bowel movements often worsen pain
Sciatica (Radicular Low Back Pain) signs
Disc herniation most likely if calf wasting, weak ankle dorsiflexion, absent ankle jerk, positive crossed straight-leg raise (pain in affected leg when healthy leg tested
Lumbar Spinal Stenosis
"Pseudoclaudication" pain in the back or
legs with walking that improves with rest, lumbar flexion
Lumbar Spinal Stenosis signs
Posture may be flexed forward, with lower
extremity weakness and hyporeflexia. Thigh
pain after 30 seconds of lumbar extension.
Straight-leg raise usually negative
Chronic Back Stiffness5
Ankylosing spondylitis, an inflammatory polyarthritis, most common in men younger than 40 years. Diffuse idiopathic hyperostosis (DISH) affects men more than women, usually 50 years or older
Pain Referred from the Abdomen or Pelvis
Usually a deep, aching pain; the level
varies with the source
Pain Referred from the Abdomen or Pelvis signs
Variable with the source. Local vertebral tenderness may be present. Spinal movements are not painful and range of motion is not affected.
Cervical Myelopathy—from cervical
Neck pain with bilateral weakness and paresthesias in both upper and lower extremities, often with urinary frequency.
Hand clumsiness, palmar paresthesias, and gait changes may be subtle.
Neck flexion often exacerbates symptoms.
Cervical Myelopathy—from cervical
cord compression signs
Hyperreflexia; clonus at the wrist, knee, or
ankle; extensor plantar reflexes (positive
Babinski signs); and gait disturbances. May
also see Lhermitte's sign: neck flexion with
resulting sensation of electrical shock
radiating down the spine. Confirmation of
cervical myelopathy warrants neck
immobilization and neurosurgical evaluation
Polymyalgia Rheumatica affects
Muscles of the hip and shoulder girdles
and neck; symmetric
Polymyalgia Rheumatica Associated symptons
swelling and edema
Tenderness-muscle- no warm or tender
Limited motion= present
Fibromyalgia Syndrome is
Widespread musculoskeletal pain and tender points.
Mechanism may involve aberrant painsignaling and amplification
Fibromyalgia Syndrome Associated symptons
Stiffness= in the morning
No limitation on motion
Chronic Tophaceous Gout Associated symptons
affects-> Feet, ankles, wrists, fingers, and elbows
Tenderness, warmth, and redness
Fever, renal failure
An inflammatory reaction to microcrystals of monosodium urate
Acute Gout Associated symptons
Tender, hot, Red
motion limited by pain
(degenerativejoint disease) affects
Knees, hips, hands (DIP PIP) cervical and lumbar spine, and wrists (first carpometacarpal joint); also joints previously injured or diseased
Osteoarthritis Associated symptons
Small effusion possible
Progressive decreased in ROM
Rheumatoid Arthritis affects
Hands (proximal interphalangeal and metacarpophalangeal joints), feet (metatarsophalangeal joints), wrists, knees, elbows, ankles
Chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone, and damage to ligaments and tendons
Rheumatoid Arthritis Associated symptons
tender, warm. not red
ROM decrease develops
Rotator Cuff Tendinitis (Impingement Syndrome)
Repeated shoulder motion can cause edema and hemorrhage followed by inflammation
most commonly involving the supraspinatus tendon.
Acute, recurrent, or chronic pain may result, often aggravated by activity.
Patients report sharp catches of pain, grating, and weakness when lifting the arm overhead.
When the supraspinatus tendon is involved, tenderness is maximal just below the tip of the acromion.
In older adults, bone spurs on the undersurface of the
acromion may contribute to symptoms.
Rotator Cuff Tears
The rotator cuff muscles and tendons compress the humeral head into the concave glenoid fossa and strengthen arm movement—the subscapularis in internal rotation, the supraspinatus in elevation, and the infraspinatus and
teres minor in external rotatio
Rotator Cuff Tears results from
Injury from a fall, trauma, or repeated impingement against the acromion and the coracoacromial ligament may
cause a partial or full-thickness tear of the rotator cuff, the most common clinical problem of the shoulder, especially in older patients.
degenerative process in the tendon associated with the deposition of calcium salts that usually involves the supraspinatus tendon.
Acute, disabling attacks of shoulder pain may occur, usually in patients older than age 30, more often in women. The arm is held close to the side, and all motions are severely limited by pain. Tenderness is maximal below the tip of
the acromion. The subacromial bursa, which overlies the supraspinatus tendon, may be inflamed. Chronic, less severe pain may also occur
Inflammation of the long head of the biceps tendon and tendon sheath causes anterior shoulder pain resembling and often coexisting with rotator cuff tendinitis. Both conditions may involve impingement injury. Tenderness is maximal in the bicipital groove. Externally rotate and abduct the arm to separate this area from the subacromial tenderness of supraspinatus tendinitis. With the patient's arm at the side, elbow flexed to 90 degrees, ask the patient to supinate the forearm against your resistance. Increased pain in the bicipital groove confirms this condition. Pain during resisted forward flexion of the shoulder with the elbow extended is also indicative
Adhesive Capsulitis (Frozen Shoulder)
manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive
range of motion, especially in external rotation, with localized tenderness. The condition is usually unilateral and occurs in people aged 40 to 60. There is often an antecedent disorder of the shoulder or another condition (such as myocardial infarction) that has decreased shoulder movements. The disorder may take 6 months to 2 years to resolve.Stretching exercises may help.
common, usually arising from prior direct injury to the shoulder girdle with resulting degenerative changes. Tenderness is localized over the acromioclavicular joint. Patients report pain with movements of the scapula and arm
Anterior Dislocation of the Humerus
results from a fall or forceful throwing motion, then can become common unless treated or the precipitating motion is avoided. The shoulder seems to "slip out of the joint" when the arm is abducted and externally rotated, causing a positive apprehension sign for anterior instability when the examiner places the arm in this position. Any shoulder movement may cause pain, and patients hold the arm in a neutral position. The rounded lateral aspect of the shoulder appears flattened. Dislocations may also be inferior, posterior (relatively rare), and multidirectional
Swelling and inflammation of the olecranon bursa may result from trauma, gout, or rheumatoid arthritis. The swelling is superficial to the olecranon process and may reach 6 cm in diameter. Consider aspiration for both diagnosis and symptomatic relief
develop at pressure points along the extensor surface of the ulna in patients with rheumatoid arthritis or acute rheumatic fever. They are firm and nontender. They are not attached to the overlying skin but may be attached to the underlying periosteum. They can develop in the area of the olecranon bursa, but often occur more distally
Arthritis of the Elbow
Synovial inflammation or fluid is felt best in the grooves between the olecranon process and the epicondyles on either side. Palpate for a boggy, soft, or fluctuant swelling and for tenderness. Causes include rheumatoid arthritis, gout and pseudogout, osteoarthritis, and trauma. Patients report pain, stiffness, and restricted motion
Lateral epicondylitis (tennis elbow)
follows repetitive extension of the wrist or
pronation-supination of the forearm. Pain and tenderness develop 1 cm distal to the lateral epicondyle and possibly in the extensor muscles close to it. When the patient tries to extend the wrist against resistance, pain increases
Medial epicondylitis (pitcher's, golfer's, or Little League elbow)
follows repetitive wrist flexion, as in throwing. Tenderness is maximal just lateral and distal to the medial epicondyle. Wrist flexion against resistance increases the pain.
Acute Rheumatoid Arthritis
Tender, painful, stiff joints in rheumatoid arthritis, usually with symmetric involvement on both sides of the body. The proximal interphalangeal, metacarpophalangeal, and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the proximal interphalangeal joints in acute disease.
Chronic Rheumatoid Arthritis
swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints. Range of motion becomes limited, and fingers may deviate toward the ulnar side. The interosseous muscles atrophy.
Chronic Rheumatoid Arthritis fingers show
show "swan neck" deformities (hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints). Less common is a boutonnière deformity (persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint). Rheumatoid nodules are seen in the acute or the chronic stage
on the dorsolateral aspects of the distal interphalangeal joints from bony overgrowth of osteoarthritis.Usually hard and painless, they affect the middle-aged or elderly; often associated with arthritic changes in other joints. Flexion and deviation deformities may develop
on the proximal interphalangeal joints are less common. The metacarpophalangealjoints are spared.
Chronic Tophaceous Gout
The deformities of long-standing chronic tophaceous gout can mimic rheumatoid arthritis and osteoarthritis. Joint involvement is usually not as symmetric as in rheumatoid arthritis. Acute inflammation may be present
Knobby swellings around the joints ulcerate and discharge white chalklike urates suggest
Chronic Tophaceous Gout
thickened nodule overlying the flexor tendon of the ring finger and possibly the little finger near the distal palmar crease. Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops between palm and finger.
Finger extension is limited, but flexion is usually normal. Flexion contracture of the fingers may gradually ensue in this condition
caused by a painless nodule in a flexor tendon in the palm, near the metacarpal head. The nodule is too big to enter easily into the tendon sheath during extension of the fingers from a flexed position. With extra effort or assistance, the finger extends and flexes with a palpable and audible snap as the nodule pops into the tendon
Identifying rotator cuff tear
Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead. Weakness or tears of the tendons usually start in the
supraspinatus tendon and progress posteriorly and anteriorly. Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. In a complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder and a positive "drop arm" test
Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome. Hypothenar atrophy suggests an ulnar nerve disorder.
cystic, round, usually nontender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist.
This cyst contains synovial fluid arising
from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic cavity.
Ganglia may develop on
the hands, wrists, ankles, and feet. They can disappear spontaneously.
Infection of the flexor tendon sheaths, acute tenosynovitis, may follow local injury
Arthritis vs Tenosynovitis
in Tenosynovitis- tenderness and swelling develop not in the joint but along the course of the tendon sheath, from the distal phalanx to the level of the metacarpophalangeal joint.
The finger is held in slight flexion; finger extension is very painful. This is a sign of
Acute Tenosynovitis and Thenar Space Involvement
If the infection progresses, it may extend from the tendon sheath into the adjacent fascial spaces within the palm. Infections of the index finger and thenar space are illustrated
Injury to the fingertip may result in infection of the enclosed fascial spaces of the finger pad
Severe pain, localized tenderness, swelling, and
dusky redness are characteristics of
If vesicles are present with Felon consider what?
herpetic whitlow instead, usually seen in health care workers exposed to herpes simplex virus in human saliva
tenderness over the plantar surface between the third and fourth metatarsal heads, from perineural fibrosis of the common digital nerve due to repetitive nerve irritation
Symptoms include hyperesthesia, numbness, aching, and burning from the metatarsal heads into the third and fourth toes
lateral deviation of the great toe and enlargement of the head of the first metatarsal on its medial side, forming a bursa or bunion.
Tenderness may be present from the medial malleolus down along the medial-plantar surface of the foot. Swelling may develop anterior to the malleoli
______ may be a normal variant or arise from
posterior tibial tendon dysfunction, seen in obesity, diabetes, and prior foot injury
Acute Gouty Arthritis -FEET
metatarsophalangeal joint of the great toe is the initial site of attack 50%
very painful and tender, hot, dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for a cellulitis. The ankle, tarsal joints, and knee are also commonly involved.
Most commonly involving the second toe,
a hammer toe is characterized by
hyperextension at the metatarsophalangeal
joint with flexion at the proximal
interphalangeal joint. A corn frequently
develops at the pressure point over the
proximal interphalangeal joint
A corn is a painful conical thickening of skin
that results from recurrent pressure on
normally thin skin. The apex of the cone
points inward and causes pain. Corns
characteristically occur over bony
prominences such as the fifth toe. When
located in moist areas such as pressure points
between the fourth and fifth toes, they are
called soft corns
Like a corn, a callus is an area of greatly
thickened skin that develops in a region of
recurrent pressure. Unlike a corn, a callus
involves skin that is normally thick, such
as the sole, and is usually painless. If a
callus is painful, suspect an underlying
A plantar wart is a hyperkeratotic lesion
caused by human papillomavirus, located
on the sole of the foot. It may look like a
callus. Look for the characteristic small
dark spots that give a stippled appearance
to a wart. Normal skin lines stop at the
wart's edge. It is tender if pinched side to
side, whereas a callus is tender to direct
When pain sensation is diminished or absent,
as in diabetic neuropathy, neuropathic ulcers
may develop at pressure points on the feet.
Although often deep, infected, and indolent,
they are painless. Underlying osteomyelitis
and amputation may ensue. Early detection
of loss of sensation using a nylon filament is
the standard of care in diabetes.
The sharp edge of a toenail may dig into
and injure the lateral nail fold, resulting in
inflammation and infection. A tender,
reddened, overhanging nail fold,
sometimes with granulation tissue and
purulent discharge, results. The great toe
is most often affected.
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