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Musculoskeletal 1

Advanced Physical Assessment

Risk factors for osteoporosis women over age 50, diabetes, thyrotoxicosis, steroids, other meds, use dexa scan to screen Osteoporosis: T score < – 2.5 Osteopenia: T score between – 1.0 and – 2.5
To treat osteoporosis calcium and vitamin D
The special exam maneuvers for different joints should be performed on both the right and left limbs to determine what is normal for the patient
Assess the 4 signs of inflammation swelling, warmth, redness, tenderness
Crepitus osteoarthritis
Musculoskeletal strength grades 0-5, look for the middle which is 3- Can move joint against gravity but not against resistance
Barlow-Ortolani maneuver to detect hip dislocation or subluxation should be performed each time you examine the infant during the first year of life
Allis sign to detect hip dislocation: when one knee appears lower than the other, the Allis sign is positive- Examination for the Allis sign. Unequal upper leg length would indicate a positive sign
Shoulder has 3 joints sternoclavicular joint, acromioclavicular joint and glenohumeral joint
Shoulder girdle is supported by the muscles of the rotator cuff- SITS- suprasoinatus, infrasoinatus, teres minor and subscapularis for support
Knock-knees genu valgum
Bowlegs genu varum
Evaluate rising from seated position-The “W” or reverse tailor position is commonly seen in children with in-toeing associated with femoral anteversion
Abduction for the shoulder the deltoid
TMJ asymmetry, swelling of joints, inflammation, dislocation, crepitus, The masseters: externally at the angle of the mandible, The temporals: externally, during clenching/ relaxation of jaw, The pterygoids: internally, between tonsillar pillars & mandible
TMJ arthritis/ dislocation/ and syndrome swelling, tenderness & ↓ROM, also trauma and pain & tenderness with palpation respectively
The shoulder is made of 3 joints > shoulder girdle The sternoclavicular (SC) joint, The acromioclavicular (AC) joint, and the The glenohumeral (GH) joint→ shoulder girdle →
The Shoulder Girdle: The muscles of the rotator cuff (SITS) Supraspinatus, Infraspinatus, Teres minor, and Subscapularis→responsible for stability the head of the humerus in the glenoid fossa, but they also contribute to some movements of the shoulder.
Adduction for the shoulder PECTORALIS MAJOR, teres major and latissimus tori
The deltoid muscle is key for maintaining shoulder abduction but relies on the supraspinatus muscle to initiate abduction.
Adduction of the shoulder is mediated by the pectoralis major, teres major, and the latissimus dorsi.
The subscapularis internally rotates (AKA medially rotates) the humerus, while the infraspinatus and teres minor externally rotate (laterally rotate) the humerus.
Contraction of the posterior deltoid and latissimus dorsi results in extension, while the anterior deltoid, pectoralis major, coracobrachialis, and biceps mediate flexion.
5 maneuvers to assess the SITS/rotator cuff d/o 1) painful arc test, 3) strength tests (internal/external lag test) and drop arm test, 1) external rotation resistance test
Test Painful arc test provoke pain- abduct arm from 0-180 and if there’s pain from 60-120
Painful arc test Fully abduct the patient’s arm from 0∘ to 180∘- Shoulder pain from 60∘ to 120∘ is a + test for the following disorders: subacromial impingement* & rotator cuff tendinitis.
Impingement tendon is trapped between 2 moving bones
Ten things can go wrong with the shoulder Gleno-humeral joint dislocation, Degenerative cervical disc, Impingement syndrome: THE MOST COMMON CAUSE, Calcific tendinitis, bicipital tendinitis, Tears/Inflammation of the rotator cuff
Gleno-humeral joint dislocation (Anterior dislocation of the humerus) is a cause of acute severe shoulder pain and limited range of motion- Could be traumatic or habitual (due to Multidirectional instability), Frozen shoulder (Adhesive capsulitis), Frozen shoulder (Adhesive capsulitis), Septic Shoulder, angina
Degenerative cervical disc disc will press on cervical nerve 5th, 6th and 7th root
Calcific tendinitis Calcification and degeneration of a rotator cuff tendon (most commonly the supraspinatus), X-ray,Diabetes and hypothyroidism increase the risk
Bicipital tendinitis The tendon of the long head of the biceps passes into the shoulder joint through the bicipital groove- is the usual site of bicipital tendinitis- just cut it
What is the best test for rotator cuff? MRI
Anatomical position pinky to thigh- ulna, radius goes with thumb
Tenderness: distal to the epicondyle is common in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (tennis/golfer’s elbow)
5 causes of elbow pain 1) Olecranon bursitis (trauma, gout, RA)- separate from->septic arthritis hurts more, 2) SQ rheumatoid nodules near ulna, 3) arthritis (OA, RA or septic), 4)cubital tunnel syndrome (Tinel’s sign), 5)epicondilytis/lateral or medial
Cubital tunnel syndrome ulnal nerve, medial side of the elbow- tinel’s sign (funny bone)-Numbness and tingling of the ring and small fingers, particularly at night – keeping the elbow flexed long time causes this
Lateral epicondylitis tennis elbow-repetitive extension of the wrist or pronation/supination of the forearm-Pain on the outside elbow- grasping, or handshake make worse- Wrist extension against resistance increases pain
Medial epicondylitis golfer’s elbow- inside- repetitive wrist flexion-Wrist flexion against resistance increases pain- Complications: Ulnar nerve neuropathy and/or palsy (long-term pressure/damage) Complains of numbness/tingling on the little finger and weakness of the hand.
Worse-case scenario of medial epicondylitis/ golfer’s elbow is development of a permanent deformity called a “claw hand”
Scaphoid bone can be missed in XR- needs to be repeated in a couple of weeks- painful and takes a long time to heal- sometimes doesn’t heal normal
MCP- metacarpal pharyngeal joints RA loves
DIP distal intralaryngeal joint- the tip- RA does not affect but OA with nodules (as well as PIP)
Carpal tunnel medial nerve- runs under flexor retinaculum (connects radius and ulna) and when compressed numbs 3 fingers (thumb, pointer, middle, ½ ring) – atrophy of thenar eminence
OA nodes in hands loss of cartilage and friction-new bone formation- Heberden nodes in DIP joints & Bouchard nodes in PIP joints
RA deformities in hands Symmetric deformities in PIP, MCP, and wrist joints. Later, subluxation and ulnar deviation of MCP joints
Carpal tunnel syndrome median nerve compression causes thenar atrophy (more common)
Ulnar nerve compression leads to hypothenar atrophy (the side of your pinky)
Snuffbox Tenderness: with the wrist in ulnar deviation and pain at the scaphoid tubercle are suggestive for occult scaphoid fx.
Anatomic snuffbox hollow space distal to the radial styloid process; thumb extensor & abductor tendons
The MCPs are often boggy and tender in RA but are rarely involved In OR
OA: Heberden nodes hard dorsolateral nodules on DIP ONLY in OA and never affected in RA
Psoriatic arthritis DIP joints are also involved
Test Sensation of hand, median, ulnar and radial Median- thumb, pointer, index, ½ ring (↓carpal tunnel) Ulnar: 5th finger/pinky and ½ ring, Radial: web of thumb and index finger
Hand grip- Ask the patient to grasp your 2nd and 3rd fingers using the thumb side of hand d/t 1) degenerative arthritis 2)epicondylitis 3) carpal tunnel syndrome 4) cervical radiculopathy- Grip weakness + wrist pain = de Quervain tenosynovitis
Thumb movement (Finkelstein test)-grasp the thumb against the palm for an ulnar deviation of wrist- Pain= de Quervain tenosynovitis from inflammation of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheathe
Carpal tunnel compression testing for median nerve compression- none very good (Durkan’s)- Most sensitive Pain/paresthesia in the median nerve after pressing for 30 sec. 2)thumb abduction, 3)Tinel sign 4)Phalen sign
Acute Rheumatoid arthritis tender, painful, stiff joints, usually symmetric involvement on both sides of the bodyThe MCP, PIP, and wrist are commonly affected; (DIP much less commonly affected)
Chronic Rheumatoid arthritis Swelling and thickening of MCP & PIP; (DIP much less commonly affected), Limited ROM with ulnar deviation of fingers, Swan neck deformity & boutonnière deformity & rheumatoid nodules
Osteoarthritis: (Degenerative joint disease) Heberden nodes on the dorsolateral aspects of the DIP joints (hard& painless) and Bouchard nodes: on the PIP joints are less common; MCP joints are spared
Chronic Tophaceous Gout Deformities in hand joints that mimic RA and OA; less symmetric than in RA- Knobby swellings around the joints ulcerate and discharge- white chalk-like urates
Dupuytren Contracture Thickened band overlying the flexor tendons of the 4th (or 5th ) finger- Subsequently the skin puckers and a fibrotic cord develops between the palm & finger
Trigger Finger Caused by a painless nodule in the flexor tendon of a finger in the palm. A palpable& audible snap is noticed on attempting extending/flexing the finger with extra effort/assistance. (watch, listen & palpate the nodule on ext./flex.)
Thenar Atrophy Suggests a median nerve disorder as carpal tunnel syndrome
Ganglion Cystic, round, usually nontender swellings along tendon sheathes or joint capsules, frequently at the dorsum of the wrist (but could happen anteriorly too). They can disappear spontaneously, or might need aspiration or excision
Acute tenosynovitis Inflammation of the flexor tendon sheaths may follow local injury, overuse, or infections; tenderness& swelling along the course of the tendonThe finger is held in slight flexion, finger extension is very painful
De Quervain’s tenosynovitis tenosynovitis of APL and EPB tendons- caused by repetitive grasping, turning/wringing motions (golfers, racquet sports)- also postpartum- pain,creaking w/movement of thumb & gripping or raising objects-may go up forearm or down the thumb. do Finkelstein
avulsion fracture bone comes off by the tendon- yanks it off by force
Colle’s fracture left wrist dinner fork deformity, pt fell on am- distal radius broken
Anatomy to know in the hip Iliac crest, Iliac tubercle, Anterior superior iliac spine (muscles attached to it), Greater trochanter (covered by burssa- pain), Pubic tubercle, Posterior superior iliac spine, Greater trochanter, Ischial tuberosity, Sacroiliac joint
Iliopsoas appendicitis
Stance phase 60% weight bearing- most hip issues here
Swing phase when walking- 40% walking cycle
Palpate the Bony Landmarks of the Hip Anterior: Iliac crest, Iliac tubercle, Anterior superior iliac spine, Greater trochanter, Pubic tubercle, Posterior: Posterior superior iliac spine, Greater trochanter, Ischial tuberosity, Sacroiliac joint
Palpate the Inguinal Structures inguinal ligament (Anterior superior iliac spine to Pubic tubercle) Lat. To Med NAVEL: Nerve- Artery- Vein- Empty space- Lymph node
Causes of groin tenderness are synovitis of hip joint, arthritis, bursitis, or psoas abscess
Palpate the Trochanteric bursa resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa, over the greater trochanter for tenderness of trochanteric bursitis
Palpate the Ischiogluteal bursa For tenderness of ischiogluteal bursitis or “weaver’s bottom” from prolonged sitting
Specific Hip Joint Tests- Thomas Test Is used to Detect flexion contractures of hip masked by excessive lumbar lordosis Lifting the extended leg off the examining table indicates hip flexion contracture in the extended leg
Trendelenburg Test Detect weak hip abductor muscle When the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight-bearing side are weak
FABER Test (AKA Patrick's test) the heel of the leg is placed on the medial side of the extended opposite knee= flexing the hip and the knee (“figure 4”position).The flexed knee is slowly moved laterally to the table, which places the hip in Flexion, ABduction, and External Rotation
FABER Test (AKA Patrick's test) positive result - Pain in the hip or low back, or limitation in ROM, suggests intra- articular hip lesions, iliopsoas pain, or sacroiliac disease (if pain is posterior)
FADIR Test performed by Flexing the patient’s hip to 90 degrees, and then ADducting and Internally Rotating the hip. If the patient has hip or groin pain, the test is positive, suggesting FAI (femoracetabular impingement) or a tear of the hip labrum.
Greater Trochanteric bursitis (MOST COMMON CAUSE HIP PAIN )Pain occurs laterally over hip just posterior to greater trochanteric bursa and radiate down the lateral leg to the foot mimicking sciatica- when they stand- improves with limited walking
Lumbar Spine Disorders herniated lumbar disc may cause sharp or "lightning like" pain in the hip or buttocks due to pain radiation down the dermatome of the involved nerve root
Intra-abdominal pathology Retroperitoneal bleeding may present with pain in the anterior thigh, also Inguinal hernias may present as hip pain, Aortoiliac occlusive disease (Leriche’s syndrome) may present as buttock, hip and thigh claudication
Septic hip would present with inability to bear weight and severe acute pain that worsens with attempted hip ROM (range of motion), including with log roll.
7 things to look for in the knee 1. Medial meniscus 2. Lateral meniscus 3. Lateral collateral ligament 4. Medial collateral ligament 5. Anterior cruciate ligament 6. Posterior cruciate ligament 7. Patellar tendon
What do you look for in a knee exam the gait- the knee should be extended when the heel strikes the ground and should be flexed at all other times- if they are “giving way”- could be quadriceps weakness
Swellings of the knee Swelling over the patella occurs in prepatellar bursitis (housemaid’s knee). Swelling over the tibial tuberosity suggests infrapatellar bursitis
Medial & Lateral Menisci medial more common- tenderness after trauma- palpated along the medial and lateral sides respectively- anterior/cruciate ligament injury cannot continue the game- meniscus can
Prepatellar bursitis is triggered by excessive kneeling; in front of patella- housemaid bursitis
anserine buritis from running, valgus knee deformity or OA. On lateral side
Baker cyst from RA- on posterior side
Patellofemoral Pain Syndrome diagnosed by any two of the following- pain with quadriceps contraction- pain with squatting- pain with palpation of the posteromedial/or lateral patellar border
Knee joint effusion testing- The bulge sign (for minor effusions). A fluid wave or bulge on the medial side between the patella and the femur after a lateral tap is a positive test for effusion
The balloon sign:(for major effusions) A palpable fluid wave is positive for effusion, or a palpable returning fluid wave into the suprapatellar pouch further confirms a major effusion
What is the test for meniscus injury Mcmurray- click or pop is positive- McMurray Test:
A palpable click or pop along the medial joint line is a positive test for a tear of the posterior portion of the medial meniscus. External rotation of the lower leg, stresses the medial meniscus. Internal rotation of the lower leg, stresses the lateral meniscus
Can you get back to the game with meniscus injury? Yes but you have a serious injury
Testing the Posterior Cruciate Ligament* Posterior Drawer Sign: If the proximal tibia falls back, this is a positive test for PCL injury-
Test question? Which test do you start with, the anterior or the posterior drawer? posterior drawer- always exclude the PCL before the anterior cruciate ligament
Testing the Anterior Cruciate Ligament* Anterior Drawer Sign: Better sensitivity and specificity in chronic ACL- Forward slide of proximal tibia is a positive sign in ACL tear- always test PCL 1st
Lachman Test for ACL also- Significant forward excursion of the tibia is a sign of ACL tear (better in chronic cases)- always test PCL 1st
ACL injuries result from knee hyperextension, direct blows to the knee, and twisting or landing on an extended hip or knee
Ottawa Knee Rules: Knee X-ray Indications, A knee x-ray is required for knee injury patients in any of the following FIVE conditions 1) Age ≥ 55 years, 2) Isolated patella tenderness, 3)Tenderness at head of fibula, 4) Inability to flex knee 90∘, 5) inability to bear weight,(4 steps) immediately after injury and in the ED
Abnormalities of the knee- Degenerative Arthritis (Osteoarthritis) after age 50; obesity, medial joint line tenderness, palpable osteophytes, bowleg appearance, suprapatellar bursae and joint effusion, also RA- Swelling, systemic involvement, SQ nodules
Abnormalities of the knee- bursitis Inflammation and thickening of bursa seen in repetitive motion and overuse syndromes- prepatellar bursa (“housemaid’s knee”) or pes anserine bursa medially (runners)
Iliotibial band friction syndrome the most common cause of lateral knee pain in long distance runners and bicyclists-friction of the iliotibial band on a bursa that overlies the lateral femoral condyle when the knee is repeatedly bent and straightened-tightness/ burning pain
Iliotibial band friction syndrome Exam shows tenderness over the lateral femoral epicondyle, and the lateral knee pain is reproduced when the patient squats- runners/bicyclists
Chondromalacia (aka: Patellofemoral Syndrome) Aggravation of ant knee pain during wt bearing w/the knee in flexion (stair climbing, arising from a sitting position) suggests chondromalacia of articular surface of the patella (AKA patellofemoral syndrome)- +grind - quadriceps are weak- young female
chondromalacia develops when the patella is pulled off toward one side of knee by the quadriceps ms (associated w/ increased Q angle: the angle between a line drawn from anterior superior iliac spine (ASIS) to the middle of patella) or cartilage of posterior side of patella wears down d/t OA
J-sign in chostochondritis- the patella tracks in the shape of a J, starting too far lateral when the knee is fully extended, and then “jumping” into the trochlear groove early in flexion
Which 2 menisus get injured the most? the medial and anterior
How do we test for the posterior and the anterior? posterior- the posterior drawer- for the anterior, the anterior drawer and lashman test
How do you test for meniscal tear? mcmurray sign
Special tests for meniscal tear? Thessaly Test, McMurray Test, Apley’s Test
Test question- Meniscal tear is r/t Joint line tenderness is the most sensitive physical finding- Ask the patient to squat. Posterior knee pain with squatting is indicative of a possible meniscal tear
ACL tears commonly occur with noncontact pivoting (twisting) injuries to the knee, popping sensation, severe pain, commonly produces a bloody knee effusion, Tense swelling during the immediate two-hours- cannot return to the game like meniscal tear
PCL tears occur dashboard injury- a blow to the anterior- Swelling is prominent and occurs almost immediately-ligament is outside the knee joint, bleeding into the joint does not typically occur.
Baker cyst on the back/popliteal surface – occurs in RA- complaints of aching or fullness behind the knee.
Septic Knee an infection inside the knee joint that would present with inability to bear weight and severe acute painthat worsens with attempt
Created by: arsho453