Lesson 10 - Msk: Ue And Spine

Front 1

Synovial joint: def and ex

Back 1

- Freely moveable
- Bones covered by articular cartilage and separated by a synovial cavity that cushions mvmt
- Ex: knee and shoulder

Front 2

Spheroidal synovial joint: def, mvmts, and ex

Back 2

- Ball and socket
- Wide range flex, ext, abd, add, rotation, circum.
- Ex: *shoulder, *hip

Front 3

Hinge synovial joint: def, mvmts, ex

Back 3

- Motion in one plane
- Flex, ext
-Ex: *IP joints of hand and foot, *elbow

Front 4

Condylar synovial joint: def, mvmt, ex

Back 4

- Mvmt of 2 articulating surfaces
- Not dissociable
- Ex: *knee, *TMJ
- Oval articulating surface sits in depression of another

Front 5

Cartilaginous joint: def and ex

Back 5

- Slightly moveable
- Ex: *Vertebral bodies of spine, public symphysis

Front 6

Fibrous joints: def and ex

Back 6

- Immoveable, bones almost in direct contact
- Ex: *skull sutures

Front 7

Common or concerning MSK sx

Back 7

- LBP
- Neck pain
- Mono or polyarticular joint pain
- Inflammatory or infectious joint pain
- Joint pain w/ systemic features - chills, fever, rash, anorexia, weight loss, weakness
- Joint pain w/ sx from other organ systems

Front 8

One of the leading complaints of pts seeking health care

Back 8

Joint pain

Front 9

Assessing joint pain

Back 9

- *"Point to pain"
- Clarify and record *MOI*
- *Determine if pain is localized or diffuse, acute or chronic, inflammatory or non-inflammatory

Front 10

LBP reg flags

Back 10

- > 50yo
- Hx of CA
- Weight loss
- Nocturnal pain or pain increased w/ rest
- Hx of IVDU
- Presence of inf or fever

Front 11

LBP red flags + bowel/blader dysfunction =

Back 11

CES
- Lesion L1-S5

Front 12

Leg or LBP that improves w/ rest and/or lumbar flexion =

Back 12

Spinal stenosis

Front 13

Joint pain + Conjunctivitis + urethritis =

Back 13

Reiter's Syndrome

Front 14

Joint pain w/ a preceding sore throat, think...

Back 14

*Acute rheumatic fever or gonococcal arthritis

Front 15

Joint pain, diarrhea, and abd pain, think...

Back 15

Ulcerative colitis or scleroderma

Front 16

S/S of inflammation and arthritis

Back 16

- *Swelling - synovial membrane boggy or doughy?, effusion w/in joint space?, soft-tissue swelling?
- *Warmth - use backs of fingers to assess
- *Tenderness
- *Redness - least common sign of inflammation near the joints

Front 17

TMJ: description

Back 17

- Most active joint in body
- Condylar synovial joint cushioned by fibrocartilaginous disc

Front 18

Principal mm opening and closing mouth

Back 18

- Opening - pterygoids
- Closing - masseter, temporalis, internal pterygoids (all CN V)

Front 19

Normal ROM of TMJ

Back 19

- Opening and closing - normal 3 fingers can be inserted
- Protrusion and retraction
- Lateral

Front 20

TMJ Syndrome: features, PE, DDx, and Trauma

Back 20

- Unilateral chronic pain w/ chewing, jaw clenching, or teeth grinding, often assoc. w/ stress (may also present w/ HA)
- PE: swelling, tenderness, and decreased ROM
- DDx: temporal arteritis, trigeminal neuralgia
- Trauma: possible dislocation, palpable crepitus, or clicking in poor occlusion, meniscus injury, or synovial swelling from trauma

Front 21

Shoulder anatomy: joints

Back 21

Glenohumeral, Sternoclavicular, AC

Front 22

MM of the shoulder joint

Back 22

- *Scapulohumeral group - SITS - lateral rotation (rotator cuff)*
- Axioscapular group - trap, rhomboids, serratus anterior, lev scap - pulls shoulder back
- Axiohumeral group: pec major and minor, and lat dorsi - internal rotation

Front 23

Bony landmarks to palpate on shoulder exam

Back 23

- *SC joint to AC joint*
- Papate spine of scapular laterally to * acromion and * AC joint
- *Coracoid process
- *Greater tubercle of humerus
- *Bicipital groove
- * Subacromial and subdeltoid bursae and SITS mm*

Front 24

How to palpate subacromial bursae

Back 24

- Passively extend humerus, inferior and lateral to acromion

Front 25

MM under subacromial bursae

Back 25

SITS mm

Front 26

Most damaged m of rotator cuff

Back 26

Supraspinatus

Front 27

Pain in bicipital groove

Back 27

Bicipital tendonitis

Front 28

MM involved w/ flex of shoulder

Back 28

- Ant deltoid
- Pec major
- Biceps
- Coracobrachialis

Front 29

MM involved w/ ext of shoulder

Back 29

- Lat dorsi
- Teres major
- Post deltoid
- Triceps

Front 30

MM involved w/ abd of shoulder

Back 30

- Suprapsinatus
- Middle deltoid
- Serratus anterior

Front 31

Scapulothoracic motion

Back 31

After raising arm 90 degrees (glenohumeral motion), raising additional 60 degrees w/ palm up is scapulothoracic
- final 30 degrees is combined scapulothoracic and glenohumeral

Front 32

Assessing add ROM of shoulder joint tests___ and mm involved are _____

Back 32

- *AC joint stability - AKA crossover sign*
- MM: pec major, coracobrachialis, lat dorsi, teres major, subscapularis

Front 33

MM involved w/ internal rotation of shoulder joint

Back 33

- Subscapularis, anterior deltoid, pec major, teres major, lat dorsi

Front 34

MM involved w/ external rotation of shoulder joint

Back 34

- Infraspinatus, teres minor, post deltoid

Front 35

Special maneuver used to assess overall shoulder rotation/AC joint stability

Back 35

- *Apley scratch test
- Scratching the opposite scapula (over the head and under)
- Difficulty doing this suggests rotator cuff disorder

Front 36

Impingement of rotator cuff mm occurs b/w ____ and ____

Back 36

Head of humerus and acromion

Front 37

*Neer's sign: What does it test, how is it performed, and what does + mean?

Back 37

- Special maneuver to test for impingement of rotator cuff
- Hold scapula to prevent motion and raise pt's arm
- Positive = Pain

Front 38

*Hawkin's sign: What does it test, how is it performed, and what does + mean?

Back 38

-Special maneuver to test for impingement of rotator cuff
- Flex pt's shoulder and elbow to 90 degrees w/ palm down
- Holding arm and forearm, rotate internally
- Positive = Pain

Front 39

*Empty can test: What does it test, how is it performed, and what does + mean?

Back 39

- Special maneuver to test for supraspinatus strength
- Have pt resist pressure applied to forearms
- Positive = weakness (possible rotator cuff tear)

Front 40

*Drop arm test: What does it test, how is it performed, and what does + mean?

Back 40

-Special maneuver to test for supraspinatus strength
- Abduct pt's arm to 90 degrees and have pt lower arm slowly
- Positive = unable to lower smoothly (possible rotator cuff tear)

Front 41

*Yergason's test: What does it test, how is it performed, and what does + mean?

Back 41

- Special maneuver to test biceps for pathology via supination
- Flex elbow to 90 degrees w/ pronation
- Have pt supinate as you resist holding the wrist
- Positive = pain and clicking, biceps tendon injury (or possible rotator cuff tear - text)

Front 42

*Speed's test: What does it test, how is it performed, and what does + mean?

Back 42

- Special maneuver to test biceps for pathology
- Flex shoulder to 90 w/ supination
- Have pt flex elbow while you resist
- Positive = Pain

Front 43

*Sulcus sign: What does it test, how is it performed, and what does + mean?

Back 43

- Special maneuver that tests GH joint stability
- With pt's arm relaxed at side, grasp forearm and pull downward while observing joint
- Positive = Sulcus sign

Front 44

*Apprehension test: What does it test, how is it performed, and what does + mean?

Back 44

- Special maneuver that tests anterior stability of shoulder
- Abd shoulder to 90 and externally rotate
- *Positive = pain or apprehension (arm seems to "slip out of the joint" w/ abd and ext rotation)*

Front 45

Area of maximum tenderness in rotator cuff tendonitis w/ suprapinatus involved

Back 45

Just below tip of acromion

Front 46

Rotator cuff tendonitis - MOI, pts c/o, MC involved tendon, and MC pt demographic

Back 46

- MOI: repeated shoulder motion, ie: throwing, swimming
- Pain aggravated by activity
- Pts c/o catches of pain, grafting, and weakness when lifting arm overhead
- MC involves the supraspinatus tendon
- Pts are MC athletically active

Front 47

Rotator cuff tear: when arm is raised in forward flexion, the rotator cuff may impinge against _______ and _____.
MOI
MC in pts _____
Can lead to ....

Back 47

- Impingement against undersurface of the acromion and the coracoacromial ligament
- Injury from fall or repeated impingement may weaken rotator cuff , causing a partial or complete tear
- MC > 40yo
- Weakness and atrophy of the supraspinatus and infraspinatus mm, pain and tenderness may ensue

Front 48

In a complete tear of supraspinatus tendon, PE will show

Back 48

- "Shrugging of shoulder" during active abd and forward flex of GH joint
- Positive "drop arm" test

Front 49

Calcific tendinitis: def, m MC involved, age, presentation

Back 49

- Tendon degenerates d/t deposition of Ca salts
- Usually involves supraspinatus
- Acute, disabling attacks of shoulder pain, MC in pts > 30yo (more often in women)
- Arm is held close to side
- All motions severely limited by pain

Front 50

Bicep tendonitis: def, pain where, PE

Back 50

- Inflammation of long head tendon and tendon sheath
- Causes ant shoulder pain resembling and often coexisting w/ rotator cuff tendinitis
- Max tenderness in bicipital groove
- Ext rotate and abd arm to separate this area from subacromial tenderness or supraspinatus tendinitis
- Yergason's positive

Front 51

Adhesive capsulitis: def, age, PE findings

Back 51

- "Frozen Shoulder Syndrome"
- Fibrosis of GH joint capsule
- Diffuse, dull, aching pain in shoulder and progressive restriction of active and passive ROM
- Usually no localized tenderness
- Usually unilateral and occurs in ppl 50-70yo
- Chronic, lasting months- yrs

Front 52

AC arthritis: def, MOI, pain w/ ....

Back 52

- Uncommon
- Usually arising form direct injury to the shoulder girdle w/ resulting degenerative changes
- Tenderness over AC joint
- GH joint motion not painful, but mvmt of scapula (ie: shoulder shrugging) is painful

Front 53

Humerus MC dislocates

Back 53

Anteriorly, normally rounded shoulder appears flat

Front 54

Joints of the elbow

Back 54

- Radiohumeral
- Humeroulnar
- Radioulnar

Front 55

Elbow PE: inspect for these 5 things

Back 55

- Joint symmetry
- Alignment
- Bony deformities
- Swelling
- Color changes

Front 56

Elbow PE: palpate these 4 things

Back 56

- Olecranon
- Medial epicondyle
- Lateral Epicondyle
- Epicondylar grooves

Front 57

*Medial epicondylitis: def, MOI, pain where and when

Back 57

- *Pitcher's/ golfer's/ Little League elbow
- D/t repetitive wrist flexion (ie: throwing)
- Tenderness max lateral and distal to medial epicondyle
- Pain increased w/ wrist flex against resistance

Front 58

Olecranon is displaced _____ in _____ and ________

Back 58

Displaced posteriorly in posterior elbow dislocation and supracondylar fx

Front 59

Elbow flex mm

Back 59

- Biceps
- Brachialis
- Brachioradialis

Front 60

Elbow ext mm

Back 60

- Triceps
- Anconeus

Front 61

Supinator mm

Back 61

- Biceps
- Supinator

Front 62

Pronator mm

Back 62

- Pronator quadratus and teres

Front 63

*Lateral epicondylitis: def, MOI, pain where and when

Back 63

- *Tennis elbow
- D/t repetitive ext of wrist or pro-sup of forearm
- Pain & tenderness @ lateral condyle and possibly ext mm close by
- Pain increases when ext the wrist against resistance

Front 64

Olecranon bursitis: def, MOI, PE findings, common in ____

Back 64

- Swelling and inflammation of bursa
- D/t trauma, RA, or gouty arthritis
- Swelling superficial to olecranon process
- Common in truck drivers and students

Front 65

Assessing for arthritis of the elbow joint

Back 65

- Synovial inflammation of fluid is felt best in grooves b/w olecranon process and epicondyles
- Palpate for boggy, soft, or fluctuant swelling and for tenderness

Front 66

RA nodules: description, location

Back 66

- Subq nodules develop @ pressure points along ext surface of ulna in RA pts (or in pts w/ acute rheumatic fever)
- Firm, non-tender
- Moveable: (Not attached to overlying skin and may or may not be attached to the underlying periosteum)
- May develop in area of the olecranon bursa, but often occur more distally

Front 67

Nursemaid's elbow: description and d/t tear in ....

Back 67

- Radial head subluxation d/t tear in annular ligament

Front 68

Wrist joints

Back 68

- Radiocarpal - "wrist joint"
- Distal radioulnar joint
- Intercarpal joints

Front 69

___ ext tendons cross wrist and hand
___ flex tendons cross wrist and hand

Back 69

6
2

Front 70

*Herberden's nodes

Back 70

OA nodules @ DIP

Front 71

*Bouchard's nodes

Back 71

OA nodules @ PIP

Front 72

Compression of what nerve causes *thenar atrophy? AKA...

Back 72

- Carpal tunnel syndrome D/t compression of median n

Front 73

Compression of what n causes hypothenar atrophy?

Back 73

- Dt/ compression of ulnar nerve

Front 74

Duputyren's contractures

Back 74

- Flexion contractures in 3rd, 4th, and 5th fingers d/t thickening of palmar fascia
- 1st sign = thickened plaque overlying the flexor tendon of the ring finger and possibly the little finger @ level of distal palmar crease
- Skin in this area puckers and thickened fibrotic cord develops b/w palm and finger
- May gradually ensue

Front 75

Signs of RA in hands and wrist

Back 75

- Symmetrical deformity in PIP, DIP, MCP, and wrists w/ *ulnar deviation
- Often boggy and tender metacarpals

Front 76

de Quervain's Tenosynovitis

Back 76

- "Gamer's thumb"
- Inflammation of the thumb ext and abd tendon and sheaths

Front 77

Carpal Tunnel Syndrome: Def, S/S, and 3 tests to assess for CTS

Back 77

- Compression of median n
- S/S: dropping things, can't twist off lids, wrist pain, numbness in 2nd, 3rd, and half of 4th finger
-* Test for using thumb abd test* (raising thumb against resistance): weakness = positive.
- Other tests: *Tinel's sign or *Phalen's sign

Front 78

*Tinel's sign

Back 78

Tap lightly over course of median nerve to test for carpal tunnel syndrome
Positive = aching and numbness when tapped

Front 79

*Phalen's sign

Back 79

- Hold wrists in flex for 60 sec. (dorsum of hands together)
- Positive = numbness and tingling in median n distribution

Front 80

*Testing grip strength
Causes of poor grip strength

Back 80

- Assesses strength of intrinsic hand mm
- Causes: arthritis, CTS, epicondylitis, cervical radiculopathy

Front 81

*Finkelstein's test: how to perform test, what positive means, and Dx

Back 81

- Make fist w/ thumb tucked inside fist and ulnar deviate the wrist
- Positive = pain
- Dx: de Quervain's tenosynovitis d/t inflammation of abd pollicus longus and ext pollicus brevis tendons and shealths

Front 82

Acute RA PE findings in hands

Back 82

- Fusiform or spindle-shaped swelling of PIP joints in acute disease

Front 83

Signs of chronic tophaceous gout

Back 83

- Not usually symmetrical
- Acute inflammation may be present
- Knobby swelling around joints ulcerate and discharge white chalk-like urates

Front 84

Ganglion: def, location, PE findings

Back 84

- Cystic, round, usually non-tender swellings along tendon sheaths or joint capsules
- Commonly @ dorsum of hand
- More prominent w/ flexion of wrist
- May also develop elsewhere on hands, wrists, ankles and feet.

Front 85

Trigger finger: def, PE findings

Back 85

- D/t painless *nodule in flexor tendon* in palm near metacarpal head
- During flex/ext nodule pops into tendon sheath - "popping"/"snapping"
- Watch, listen, and palpate nodule while pt flex and ext fingers

Front 86

Acute tenosynovitis: def, presentation, possible complication

Back 86

- Infection of the flex tendon sheaths, may follow local injury
- Finger is held in slight flexion
- Ext is very painful
- If infection progresses, can extend from tendon into adjacent fascial spaces in palm
- Early dx and tx are important

Front 87

Curves of spine

Back 87

Cervical- lordosis, concave
Thoracic- kyphotic, convex
Lumbar - lordotic, concave
Sacrococcygeal - kyphotic, convex

Front 88

Area of back especially vulnerable to injury

Back 88

L5-S1, d/t sharp posterior angle

Front 89

Types of LBP

Back 89

- Muscular pain/spasm
- Joint sprain, inflammation, or arthritis
- Discogenic pain: bulging, protruding, herniation, infection
- Bone: fx, tumor, etc.
-Neurologic: compression or injury to the peripheral nerves, spinal cord, or components of cord

Front 90

Inspecting spine

Back 90

- Observe *posture
- Assess for erect position of head, smooth, coordinated neck mvmts, and ease of gait
- Landmarks
- Spinal curves

Front 91

Spine landmarks

Back 91

- Spinous processes
- Paravertebral mm
- Iliac crests
- PSIS
- L4 (draw an imaginary line across iliac crests)
- Shoulder symmetry

Front 92

Unequal shoulder heights seen in...

Back 92

- Scoliosis
- Winging of scapula
- Trapezius weakness

Front 93

Areas to palpate on spine exam

Back 93

- Spinous processes (w/ thumb) - note any "step offs"
- Cervical facets (w/ relaxed neck)
- SI joint
- Paravertebral mm
- Sciatic nerve (L4-S3 nerve roots)

Front 94

Spondylolithesis: def

Back 94

Forward slippage of vertebrae that can cause compression of spinal cord

Front 95

Tenderness of SI joint suggests ...

Back 95

Ankylosing spondylitis

Front 96

How to palpate *sciatic n
Tenderness of sciatic n suggests

Back 96

W/ flexed hip, lying on side - n is midway b/w greater trochanter and ischial tuberosity as it leaves pelvis via sciatic notch
Herniated disc

Front 97

Things that can cause tenderness of spinous proccesses

Back 97

Fx, infection, arthritis, or dislocation

Front 98

Percussion of spine

Back 98

Not usually done
If done, gently use ulnar surface of fist
More common to individually percuss vertebrae for fx

Front 99

Mechanical LBP

Back 99

- Pain in lumbosacral area, may radiate into lower leg
- Absence of neoplasm, infectious, or inflammatory disease
- Usually acute, benign, self-limiting
- Work -related, obesity, poor conditioning, etc.
- MC d/t muscle or ligament injuries
- Paraspinal m or facet tenderness, pain w/ back mvmt,

Front 100

Sciatica

Back 100

- Radicular LBP
- Shooting pain below knee, MC into lateral leg or post calf
- Usually accompanies LBP
- Paresthesias, weakness
- Bending, sneezing, coughing, straining during BM - worsen pain
- Very sensitive and specific for disc herniation
- MC L5-S1
- Most likely sciatica if calf wasting, weak ankle dorsiflex, absent ankle jerk, + crossed straight-leg raise

Front 101

Lumbar spinal stenosis

Back 101

- Pseudocladication w/ walking
- Relieved by rest and/or lumbar flex
- Vague pain, usually bilateral, w/ paresthesias in one or both legs
- Arises from hypertrophic degenerative disease of 1 or more vertebral facets and thickening of ligamentum flavum - narrowing of canal centrally or laterally
- More common > 60 yo
- Posture may be flexed forward w/ LE weakness and hyporeflexia
- SLR usually -

Front 102

Flex and ext of neck occurs...
MM involved

Back 102

Primarily b/w skull and C1
Flex: SCM, scalene, prevertebral mm
Ext: Splenius capitus and cervicis, small intrinsic neck mm

Front 103

MM involved w/ rotation at C1/C2

Back 103

SCM, small intrinsic neck mm

Front 104

MM involved w/ lateral bending at C2-C7

Back 104

Scalenes and small intrinsic neck mm

Front 105

MM involved w/ flex of spine

Back 105

Psoas major and minor, quadratus lumborum, abd mm attaching to anterior vertebrae (ie: int and ext abd obliques and rectus abdominis)

Front 106

MM involved w/ ext of spine

Back 106

Deep intrinsic mm of back (ie: erector spinae and transversospinalis groups)

Front 107

MM involved w/ rotation of spine and lateral bending

Back 107

Abd mm, intrinsic mm of back

Front 108

Spina bifida occulata s/s

Back 108

- Birthmarks: port-wine stains
- Hairy patches
- Lipomas
- All these often overlie bony defects, can be possibly unknown to pt

Front 109

Neurofibromatosis s/s

Back 109

- Chronic disease
- Cafe-au-lait spots
- Skin tags
- Fibrous tumors

Front 110

Osteoporosis risk factors

Back 110

- Post- menopausal white women
- > 50yo
- < 70kg
- Hx of fx
- FHx
- High alcohol intake
- Delayed menarche or early menopause
- Smoker
- Low vit D
- Use of corticosteroids > 2m

Front 111

Bone density is...

Back 111

The interaction of bone mass, new bone formation, and bone resorption/loss

Front 112

Bone quality refers to ...

Back 112

Bone architecture

Front 113

Bone density accounts for ____% of bone strength and is measured by _____.
Interpretations of bone density scores

Back 113

70%
Dexascan
Osteopenia: T score = -2.5 to -1
Osteoporosis: T score less than -2.5