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92 Cards in this Set

  • Front
  • Back

types of joints

- synovial


- cartilaginous


- fibrous

synovial joint

spheroidal (ball/socket) shoulder hip, freely moveable to flexion, extension, abduction, adduction, rotation, circumduction



hinge - elbow, finger, toes. flexion, extension



condylar- knee, TMJ. flexion, extension, rotation and motion

cartilaginous

vertebral bodies of spine - slightly moveable

fibrous

skill suture- immovable

subjective data for MSK health history

- joints: pain, stuffness, swelling, heat, redness


- muscles: pain (cramps), weakness


- bones: pain, deformity, trauma (fractures, sprains, dislocations)


- functional assessment (activities of daily living)


- self care behaviors


- family hx: osteoporosis, RA


- environmental exposure

joint pain + butterfly rash

lupus

joint pain + scaly rashand pitted nails of psorisasis

psoriatic arthritis

joint pain + papules, pustules or vesciles on reddened base found on distal extremities

gonocci arthritis

joint pain + expanding erythematous patch

lyme

joint pain + hives

serum sickness

joint pain + erosion or scaling on the penis and crusted scaling papules on the soles and palms of feet



joint pain + burning, red itching eyes

reiters syndrome

joint pain + preceding sore throat

acute rheumatic fever, gonocci arthritis

joint pain + diarrhea, abdominal pain, gramping

arthritis with ulcerative colitis, scleroderma

joint pain + mental status changes, facial weakness, stiff neck

lympe with central nervous sytem involvement

assessing joint pain

- ask the pt to point to the pain


- bespecific with the onset of pain, associated mechanism of injury if present


- is the pain localized or diffuse?


- is it intra or extra articular?


- is it acute or chronic?


- it is inflammatory or non-inflammatory?

common and/or concerning symptoms

- low back pain


-neck pain


- monoarticular or polyarticular joint pain


- inflammatory or infectious joint pain


- joint pain with systemic features such as fever, rash, chills, anorexia, weight loss, weakness


- joint pain associated with symptoms from another organ system

health promotion for osteoarthritis

screening for women >65 or younger with increased risk factors



risk factors:


- post menopausal women


- age greater than 50


- thin, weight less than 154 lbs


- low dietary calcium


- vitamin D deficiency


- tobacco or alcohol use


- use of corticosteroids



recommended dietary intake vitamin D and cacium


19-50 1,000 ca, vitamin 600


50-71 women 1,200 ca 600 vitamin men: 1,000 ca 600 Ca


> 71 1,200 Ca 600 vitamin

approach to MS exam

- during inspection, look for symmetry of involvement


- note any joint deformities or malalignment of bones


- use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle atrophy


- note any crepitus


- test range of motion and maneuver to demonstrate joint instability


- finally, test muscle strength

approach to MS exam

be alert to signs of inflammation and arthritis


- swelling: 1) the synovial membrane, which can feel boggy or doughy 2) effusion from excess synovial fluid within the joint space or 3) soft-tissue structures such as bursae, tendons, and tendon sheaths


- warmth


- tenderness


- redness


- loss of function


- deformity

order of examination

1) inspection: size and contour of joint, skin and tissues over the joint


2) palpation: skin temperature, muscles, boney articulations, area of joint capsule


3) range of motion


4) muscle testing a. apply opposing force b. grading muscle strength

grading system to assessing muscle strength is from 0-5

0 = no contraciton, complete paralysis, no visible or palpable movement


1 = slight contraction, but very severe weakness, weak contraction visible but extermity doesn't move


2= full ROM with gravity eliminated (passive motion)


3= full ROM with gravity but not against resistance (moderate weakness)


4= full ROM against gravity, with some resistance


5= full ROM against gravity, with full resistance (normal muscle strength)

cervical spine

- inspect alignment of head and neck


- palpate spinous process and muscles


- motion and expected range: chin to chest, lift chin, each ear to shoulder, turn chin to each shoulder

neck pain: mechanical

- aching pain, cervical paraspinal muscles and ligaments


-spasm, stiffness, tightness in shoulder and upper back


- duration weeks


- no radiation, paresthesia, weakness


- headache may be present


- PE point tenderness along paraspinal muscles, pain with movement but not decreased ROM, no neurologic deficits

neck pain: whiplash

- aching paracervical pain and stiffness


- begin day after the injury


- occipital headache, dizziness, malaise and fatigue present


- can be chronic lasting > 6 months


- caused by forced hyperflexion/extension


- decreased ROM, perceived weakness of upper extremities

neck pain: cervical radiculopathy

- sharp burning or tingling pain in neck and in one arm


- parasthesia and weakness in affected arm


- nerve root compression C7 most effected


- caused by nerve root compression C7 most effected


- caused by herniated disc


- PE: weakness of tricepts if C7 involved


- if C6 then weakness in biceps

neck pain: cervical myelopathy (cord compression)

- neck pain with bilateral weakness and paresthesia in both upper and lower extermities


- hand clumsiness, palmar paresthesia and gait changes ps=ossible, urinary frequency


- neck flexion exacerbates symtoms


- caused by cervical spondylosis from degenerative disc or cervical stensosis or trauma


- PE: Hyperreflexia, + babinski, gait changes


- requires neck immobilization and neurosurgical evaluation

back pain assessment questions: where is the pain?

midline (over the vertebrae)? consider injury, disc hernitation, vertebral collapse, spinal cord metastases and rarely epidural abscess



off the midline? consider muscle strain, sacroiliac inflammation (sacroilitis), trochanter bursitis, sciatica, hip arthritis and possibly renal causes such as pyelonephritis or stones

back pain assessment questions: does it radiate?

if so, where?


do you have any numbness or tingling?

back pain assessment questions: do you have any associated symptoms with the pain?

- urinary retention or overflow incontinence


- constitutional symptoms

MSK red flags

- age > 50


- hx cancer


unexplained weight loss


- pain lasting longer than a month or not responding to treatment


- pain at night or present at rest


- hx of IV drug use


- presence of infection


spine

- inspect when a person stands


- palpate spinous processes


- motion and expected range: bend sideways, backward, twist shoulders to each side


- straight leg raising


- measure leg length discrepancy

low back pain: mechanical low back pain

- aching pain in the lumboscaral area, may radiate into lower leg, especially along L5 or S1


- usually acute (<3 months), idiopathic, benign, and self-limiting


- usually worse standing and twisting moton


- 97% of low back presenations are in 30-50 y/os and are work related


- PE: paraspinal muscle tenderness, pain with movement, loss of lumbar lordosis


- no motor or sensory impairment

low back pain: sciatic (radicular low back pain)

- shooting pain below the knee, commonly into the L5 or S1 typically accompanies low back pain


- associated numbness and weakness


- bending, sitting, sneezing, coughing, straining during bowel movements often cause worse pain


- disc herniation common esp if calf wasting is present


PE: + straight leg


- negative straight leg makes dx unlikely

lumbar spinal stenosis

- "pseudocluadication" pain in the back or legs with walking that improves with rest or lumbar flexion


- pain vague but usually bilateral, with numbness in one or both legs


- hypertrophic degenerative disease, thickening of the ligament causing narrowing of the spinal canal


- common age >60


PE: posture flexed forward, lower extremity weakness, hyporeflexia

chronic back stiffness: ankylosing spondylitis

- chronic inflammartory disease progressive stiffness of the spine


- age of onset <40


- insidious onset


- progressive postural changes

chronic back stiffness: diffuse idiopathic hyperostosis (DISH)

- non-inflammatory disease


- calcification and ossification of spinal ligaments


- age onset >50


- decreased range of spinal motion, particularly thoracic movement

nocturnal back pain, unrelieved by rest

- consider metastatic malignancy to the spine from cancer of the prostate, breast, lung, thyroid and kidney and multiple myeloma



PE: loss of normal lumbar lordosis, muscle spasm, lateral immobility of the spine

cauda equina syndrome

- low back pain associated with bladder symptoms, saddle anesthesia (loss of senstation in butt and surrounding area)



- compression of the spinal nerve root



- surgical emergency as the compression is often cused by tumor ruptured disc, infection, fracture, or narrowing of the spinal canal


sacroilitis

- lumbosacral pain radiates to the butt, groin, or posterior thigh 
 
- aggravated by extensive use prolonged exercise 
 
PE: tenderness at SI joint
 
can be an overuse injury or r/t systemic illness

- lumbosacral pain radiates to the butt, groin, or posterior thigh



- aggravated by extensive use prolonged exercise



PE: tenderness at SI joint



can be an overuse injury or r/t systemic illness

shoulder exam

- inspect joint


- palpate shoulders and axilla


- motion and expected range: arms forward and up, arms behind back and hands up, arms to sides and up over head, touch hands behind head

rotator cuff tendinitis (impingement syndrome)

- usually caused from overuse or fall


- common in young adults, middle aged athletes


- minor pain that is present both with rest and activity


- pain radiating from the front of the shoulder to the side of arm


- sudden pain with lifting and reaching movements


- tenderness just below the tip of the acromion

apley test

- ask pt to touch the opposite scapula his/her arm above the shoulder and under ths shoulder


- difficulty suggests rotator cuff disorder or adhesive capsulitis

dislocated shoulder

- shoulder instability from anterior dislocation of the humerus


- the shoulder seems to "slip out of the joint"


- positive apprehension test


- any shoulder movement may cause pain, and patients hold the arm in a neutral position


- the rounded lateral aspect of the shoulder appears flattened

apprehension test

- patient is supine or sitting


- shoulder is abducted 90 degrees and elbow is bent


- examiner hand on shoulder and one on wrist


- attempt to externally rotate the shoulder


- positive test if pt has apprehension


- indicates glenohumueral instability

rotator cuff tears

in a complete tear of supraspinatus tendon (illustrated), active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive "drop arm" test



- injury from a fall or repeated impingement may weaken the rotator cuff


- causing a partial or complete tear, usually after age 40


- weakness, atrophy of the suprasinatus and infraspinatus muscles, pain and tenderness may ensue

Adhesive capsulitis (frozen shoulder)

- fibrosis of the glenohumeral joint capsule 
- manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive range of motion
 
- usually no localized tenderness
 
-usually unilateral and occurs in peop...

- fibrosis of the glenohumeral joint capsule


- manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive range of motion



- usually no localized tenderness



-usually unilateral and occurs in people aged 50 to 70



- antecedent painful disorder of the shoulder or another condition tha has decreased shoulder movements

acromioclavicular arthritis

- common
- occurs from prior injury resulting in egenerative changes in the joint
- tenderness localized to the AC joint
- pain with abduction

- common


- occurs from prior injury resulting in egenerative changes in the joint


- tenderness localized to the AC joint


- pain with abduction

elbow

- inspect joint in flexed and extended positions


- palpate joint and bony prominences


- motion and expected range: bend and straighten elbow, pronate and supine hand

olecranon bursitis

swelling and inflammation of the olecranon bursa 
 
- may result from trauma or may be associated with rheumatoid or gouty arthritis 
- goose egg or redness due to inflammation of the bursa 
- the swelling is superficial to the olecranon process

swelling and inflammation of the olecranon bursa



- may result from trauma or may be associated with rheumatoid or gouty arthritis


- goose egg or redness due to inflammation of the bursa


- the swelling is superficial to the olecranon process

arthritis

- synovial inflammation or fluid, felt in the grooves between the olecranon process and epicondyles on either side


- palpate for boggy, soft, or fluctuant swelling and for tenderness


- causes can be rhematoid, gout, osteoarthritis, trauma


- pain stiffness or restricted movement

rheumatoid nodules

- subcutaneous nodules may 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, and are not attached to the overlying skin 
- they may or m...

- subcutaneous nodules may 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, and are not attached to the overlying skin


- they may or may not be attached to the underlying periosteum


- they may develop in the area of the olecranon bursa, but often occur more distally

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

medical epicondylitis

pitchers, 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



wrist/ hand exam

- inspect joints on dorsal and palmar sides


- palpate each joint


- motio and expected range: bend hand up, bend hand down, bend fingers up, down, turn hands out and in, spread fingers, make fist, touch thumb to each finger

dupuytren's contracture

- the first sign is thickened plaque overlying the flexor tendon of the ring finger and possibly the little finger at the level of the distal palmar crease


- subsequently, the skin in this area puckers and a thickened fibrotic cord develops bt palm & finger


- flexion contracture of the fingers may gradually ensue

trigger finger

- 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


- the finger extends and flexes with a palable and audible snap; as the nodule pops into the tendon sheath


- watch, listen and palpate the nodule as the patient flexes and extends the fingers

de quervan's tenosynovitis

- pain with palpation over the tendon sheath of the thumb


- swelling may present


- numbness of thumb and index finger


- more common in women, can occur after 3-4 weeks after pregnancy



finklestein test

test for de quervan's tenosynovitis 
 
- make a fist with thumb enclosed
- flex writst, tenderness along the outer edge of the wrist

test for de quervan's tenosynovitis



- make a fist with thumb enclosed


- flex writst, tenderness along the outer edge of the wrist

carpal tunnel syndrome

- compression of the median nerve as it travels through the carpal tunnel


- pain, numbness and tingling along the distribution of the median nerve


- thelnar atrophy may be present


- phalen test: hold for 60 seconds, compress median nerve, illicits pain, tingling


- tinels tapping over the median nerve produced numbness or tingling

hip assessment

- inspect as person stands


- palpate with person supine


- motion and expected range: raise leg, knee to chest, flex knee and hip; swing foot out and in, swing leg laterally, medially; stand swing leg back

assess gait

- stance, the time the foot is on the ground bears weight weight


- most hip problems appear during the weight bearing stance phase


- swing: movement of the foot forward, non- weight bearing, wide base suggest cerebellar disease or foot problems


- swinging due to lack of knee flexion


- pelvic drop on the opposite side


- hip dislocation, arthritis, leg length, discrepancy

bursitis

- bursitis is an inflammation or degeneration of the sac- like structure that protect the soft tissue from underlying bony prominences 
- pain with movement and rest 
-swelling 
- locaized tenderness over the site of inflammation 
- if effusion pr...

- bursitis is an inflammation or degeneration of the sac- like structure that protect the soft tissue from underlying bony prominences


- pain with movement and rest


-swelling


- locaized tenderness over the site of inflammation


- if effusion present, aspirate fluid to assess for infection, gout

hip abnormalities

- flexion deformity - excess lordosis, as the opposite hip is flexed (with the thigh against the chest), the affected hip does not allow full leg extension, and the affected thigh appears flexed



- hip osteoarthitis: 1) restricted abduction 2) restriction of internal and exteral rotation

knee

- inspect join and muscle


- palpate


- motion and expected range: bend knee, extend knee, check knee with ambulating

specific knee tests

- bulge sign: milk downward, apply medial pressure, tap and watch for fluid wave



- ballottement of patella: pinch sides of knee cap

tests for stability of the medial collateral ligament (valgus stress)

- patient supine and knee slightly flexed, move the thigh about 30 laterally to the side of the table


- place one hand against the laterall knee to stabilize the femur and the other hand around he medial ankle


- push medially against the knee and pull latrally at he ankle to open the knee joint on the medial side (valgus stress)


- pain or gap in the medial joint line point to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries are on the medial side

test for stability of the laternal collateral ligaments (varus test)

- adduction (or varus) stress test


- place one hand against the medial surface of the knee and the other around the lateral ankle


- push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side (varus stress)


- pain or gap in the lateral joint line points to ligamentous laxity and partial tear of lateral collateral ligament

tests the stability of the posterior cruciate ligaments- posterior drawer test

- position the patients and place your hands in the positions described for the anterior drawer test



- push the tibia posteriorly and observe the dgree of backward movement in the femur



- isolated PCL tears are rare

what is the test for meniscal injury?

mcmurray's test

ankle/foot assessment

- inspect with person sitting, standing and walking


- palpate joints


- motion and expected range: point toes down, up, turn soles out, in, flex and straighten toes

gout

- the metatarsophalangeal joint of the great toe may be the first joint involved in acute gouty arthritis


- characterized by a very painful and tender, hot, dusky red swelling that extends beyond the margin of the joint


- it is easily mistaken for cellulitis


- acute gout may involve the dorsum of the foot


- cause by a build up of sodoum urate or uric acid which is a byproduct of purines

pseudo-gout

- calcium pyrophospahte deposition (CPPD)


- mono or poly-articular joint pain caused by build of calcium pyrophosphate in the joint


- inflammation of the joint and periarticular area may be present


- older population >60 years of age


- difficult to distinguish bt gout


- requires aspiration of synovial fluid for definitive dx

pes planus

flat feet


- could be only apparent when pt stands or may become permanent


- the longitudinal arch flattens so that the sole approaches or touches the floor


- the normal concavity on the medial side of the foot becomes convex


- tenderness may be present from the medial malleolus down along the medial- plantar surface of the foot


- swelling may develop anterior to the malleoli


- insepct the shoes for excess wear on the inner sides of the soles and heels

plantar fasciitis

inflammation of the plantar fascia



- one of the most common causes of heel pain


- age 40-60, younger in runners


- risk factors: obesity: prolonged standing or jumping, flat feet, reduced ankle dorsiflexion, heal spurs

hallux valgus

- in hallux valgus, the great toe is abnormally abducted in relationship to the first metatarsal which tiself is deviated medially


- the head of the first metatarsal may enlarge on its medial side, and a bura may form at the pressure point


- this bursa may become inflammed

feet abnormalities


pes varus


pes valgus

pes varus toes come in


pes valgus toes come out

corn

painful conical thickening of skin that results from recurrent pressure on normally thin skin



- apex of corn points inward and causes pain


- corns characteristically occur over bony prominence such as the 5th toe


- when located in moist areas such as pressure points bt 4th and 5th toes, they are called soft corns

callus

- 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 noramlly thick, such as the sole, and is usually painless


- if a callus is painful, suspect an underlying planar wart

plantar wart

- caused by HPV


- common on the ball of the foot


- can be tender to touch and painful with ambulation

arthritis: osteoarthritis

- degenerative joint disease


- breakdown of the cartilage in the joint


- age related


- non-inflammatory, can be unilateral


- affect, knees, hips, hands, spine wrists


- morning stiffness < 1 hr and late day pain, after activity


- heberden's nodes of DIP


- douchard nodes of PIP


- does not affect the MCP

arthritis: rheumatoid arthritis

- autoimmune disorder with chronic inflammation of the synovial membrane and surrounding tissue


- symmetric involvement of hands and feet, wrist, ankle, elbows, ankles


- occurs at any age


- morning stiffness > 1 hour


- joints tender, warm, red, swollen


- family hx


- fatigue


- boutonneire deformity of PIP


- swan neck deformity of finger

what should you think when you have a MSK complaint?

- intra or extra articular


- acute or chronic


- is inflammation present


- how many joints involved

non articular condition, what do you consider?

- trauma/ fracure


- fibromyalgia


- polymyalgia rheumatic


- bursitis


- tendinitis

intra articular condition, less than 6 weeks

less than 6 weeks >> acute arthtirits


infectious arthritis


gout, pseudogout


reiters syndrome


early presentation of chronic arthritis

intra articular, greater than 6 weeks

- is inflammation present?


- prolonged morning stiffness


- soft tissue swelling


- systemic symptoms


- ESR or CPR elevated


no inflammation

consider non-inflammatory arthritis ie osteoarthritis

yes for inflammation

- how many joints are involved?


more than 3 joints: risk for rheumatoid arthritis


less than three joints: psoriatic or reiters arthritis

osteoarthritis

1)herberden's nodules at PIP


2) bouchard's nodes at DCP

rheumatoid arthritis

boutonniere deformity
swan neck deformity

boutonniere deformity


swan neck deformity

reiter's syndrome

- arthritic disorder causing inflammation of the joints, commonly the spine


- inflammation of the intestinal, urinary tract, eyes and skin


- symptoms do not occur all at once and are not present with the joint pain


- more common in men


- etiology unknown: feel genetic


- dx based on good hx & physical exam

polymyalgia rheumatica

- chronic self limiting pain with unclear etiology


- usually > 50 occur with giant cell arthritis (temporal arteritis)


- symmetric pain around hip, shoulders, neck


- insidious or abrupt onset, can be night time pain


- swelling and edema may be present over dorsum of hands, wrist and feet


- muscles tender but not warm or red


- joint stiffness in AM


- pain will limit movement


- may have associated depression, anorexia, weight loss

fibromyalgia

- chronic MS pain disorder affecting the soft tissue


- felt to be r/t aberrant pain signaling that amplifies the pain response


- pain "all over" neck, shoulders, hands, low back and knees, trigger points on exam


- patters can shift, may be exacerbated by cold, immobility


- associated with fatigue, depression/anxiety, headaches, cognitive fogginess