Musculoskeletal System BATES

Flexor retinaculum:

-Holds the tendons and tendon sheath -Is a transverse ligament -Median nerve lies between this and the tendon sheath Median nerve: provides sensation to palm, most of palmar surface of thumb, second and third digits, and 1/2 of fourth digit. -Also innervates the thumb muscles of flexion, abduction, and opposition

Bony structures of the shoulder:

-Humerus -Clavicle -Scapula: anchored to axial skeleton by sternoclavicular joint and inserting muscles (scapulothoracic articulation) since it is not a true joint

Spine anatomy:

-7 cervical, 12 thoracic, 5 lumbar vertebrae -Sacrum on bottom! Muscles of the spine: -SCM, trapezius,latissimus dorsi, splenius

Calcium and Vitamin D

-<1% of total calcium supports metabolic functions; the remaining 99% are stored in teeth and bones -Without Vitamin D, only 10-15% of calcium is absorbed -PTH: essential for conversion of Vitamin D to its active form and activating osteoblasts, which do a lot

Severe pain of rapid onset in a red, swollen joint:

-Acute septic arthritis or gout -In children: osteomyelitis in bone contiguous to a joint

Stiffness and limited motion disorders:

-After inactivity (gelling): occurs in denerative joint disease, but usually only for a few minutes -Rheumatoid arthritis and other inflammatory arthritides: stiffness lasting 30 min or more -Fibromyalgia and polymyalgia rheumatica (PMR): stiffness also occurs

Ottawa ankle rule

-After trauma, inability to bear weight after 4 steps and tenderness over posterior aspects of either malleolus (esp medial): suspicious for ankle fracture

Identifying a degenerative rotator cuff tear:

-Age of 60 years or older and a positive drop-arm test -Combined findings of supraspinatus weakness, infraspinatus weakness, and a positive impingement sign increase the likelihood ratio of a tear (when these 3 are absent, you can essentially rule out this diagnosis)

With back pain, elicit any key warning signs or red flags for serious underlying systemic disease IF:

-Age older than 50 years -History of cancer -Unexplained weight loss -Pain lasting >1 month or not responding to treatment -Pain at night or present at rest -History of intravenous drug uses -Presence of infection

Risk factors falls:

-Cognitive and physiologic, including: -Unstable gait -Unbalanced posture -Loss of strength -Cognitive loss -Deficits in vision and proprioception -Osteoporosis Note: poor lighting, stairs, chairs at awkward heights, slippery or irregular surfaces, and ill fitting shoes are environmental hazards that can usually corrected

Generalized symptoms and their disorders:

-Common in rheumatoid arthritis, systemic lupus erythematosus (SLE), PMR, and other inflammatory arthritides. High fever and chills suggest infectious case

Abnormal findings with TMJ:

-Facial asymmetry is seen in TMJ syndrome -Typical features: unilateral chronic pain w/chewing, jaw clenching, or teeth grinding -Headache -Dislocation of the TMJ may be seen in trauma -Palpable crepitus or clicking--present in poor occlusion, meniscus injury, or synovial swelling from trauma ***-Pain and tenderness occur on palpation in TMJ syndrome

Septic arthritis, gout or possible rheumatic fever:

-Fever, chills, warmth,r edness

Shoulder: joints and spaces

Sternoclavicular Acromioclavicular Glenohumeral Subacromial space: -Under surface of acromion and head of humerus and coracoacromial lig -This space contains: supraspinatus muscle/tendon and subacromial bursa -Concern for impingement

Anabolic agents:

Such as parathyroid hormone: stimulate bone formation by acting primarily on osteoblasts; require subcutaneous administration and monitoring for hypercalcemia -Reserved for moderate-->severe cases of osteopenia nad patients whose bone density has not improved on bisphosophonates

Kyphosis:

Thoracic kyphosis occurs with aging. In children, correctable deformity should be pursued

Muscle groups of ankle and foot:

Tiobiotalar joint (ankle joint): limited to dorsiflexion and plantar flexion. -Plantar flexion: powered by gastrocnemius, posterior tibial muscle, and toe flexors (behind malleoli) -Dorsi flexion: anterior tibial muscle, and toe extensors (anterior surface, or dorsum of ankle, anterior to malleoli) Ligaments extend from each malleolus onto the foot: -Deltoid ligament: medially, fans out from inferior surface of medial malleolus to the talus and proximal tarsal bones, protecting against stress from eversion (heel bows outward) -Laterally the three ligaments are less substantial/higher injury risk: 1) ANterior talofibular ligament (most at risk in injury from inversion--heel bows inward) 2) Calcaneofibular ligament 3) Posterior talofibular ligament Note: Achilles tendon attaches the gastrocnemius and soleus muscles to the posterior calcaneus -Plantar fascia inserts on the medial tubercle of calcaneus

Unequal heights of iliac crests or pelvic tilt:

Unequal length of legs and disappear when a block is placed under shorter limb. Scoliosis and hip abduction or adduction can cause this

Arthritis

decreased range of motion, joints with tissue inflammation or surrounding fibrosis, or bony fixation (ankylosis)

Preservation of active elbow range of motion/full elbow extension:

After injury, this makes fracture highly unlikely -When in tact, these actions have a sensitivity of 100% and specificity of 50->97% for absence of fracture -Full elbow extension also makes intra-articular effusion or hemarthrosis unlikely

Neck pain:

Also very common, though usually self limited, it is important to ask about radiation into the arm, especially the shoulder -Be sure to elicit symptoms related to the "red flags" listed in other quizlet -Persistent pain after blunt trauma or a motor vehicle collision warrants further evaluation

Arthritic joint in foot vs ligamentous sprain:

An arthritic joint is painful when moved in any direction, while a ligamentous sprain produces maximal pain when the ligament is stretched Ex: in a foot sprain, inversion and plantar flexion of foot causes pain, while eversion and plantar flexion are relatively pain free

Fingers and thumbs: range of motion and maneuvers:

FINGERS Range of motion: flex,ext,abd,ad Flexion: "Make a tight fist with each hand, thumb across the knuckles" Extension: "Extend and spread the fingers" Adduction/Abduction: Ask pt to spread fingers apart (abduction) and back together (adduct) -Check for smooth coordinated movement THUMB: Range of motion: flex,ext,abd,add,opposition Flex: move thumb across palm and touch base of fifth finger Ext: move thumb back and away from the fingers Abd/add: pt move thumb anteriorly away from palm (abd); back down (add) Opposition: ask pt to touch the thumb to each of the other fingertips

Arthritis variations of pattern of spread:

Gonococcal arthritis: migratory pattern of spread Rheumatoid arthritis: progressive additive pattern with symmetric involvement Inflammatory arthritis: more common in women

Listing of trunk to one side:

Herniated lumbar disc

TMJ:

Most active joint in the body: -formed by the fossa and articular tubercle of the temporal bone and the condyle of the mandible -Lies midway between external acoustic meatus and zygomatic arch CONDYLAR SYNOVIAL JOINT: Principle muscles 1) External pterygoids: principle muscles that open the mouth 2) Masseter, temporalis, internal pterygoids=close the mouth (innervated by cranial nerve V, trigeminal nerve) To locate and palpate joint: place tips of index fingers just in front of the tragus of each ear and ask the patient to open his or her mouth. Fingertips should drop into the joint spaces as the mouth opens. Check for smooth range of motion: note any swelling or tenderness. Snapping or clicking is normal

Common 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, chills, rash, anorexia, weight loss, weakness Joint pain with symptoms from other organ systems

McMurray Test:

MENISCAL ASSESSMENT (Meniscus)

Low back pain:

May want to start with "any pains in your back?" because 2/3 of adults have this at least once during lifetime -2nd most common reason for office visits Determine if the pain is on the midline, over the vertebrae, or off the midline -Is there radiation into the buttock or lower extremity? Is there any associated numbness or paresthesias? -What about associated bladder or bowel dysfunction? Note: for low back pain plus another indicator: 10% probability of serious systemic disease

Mono vs. Poly vs. extra-articular articular joint pain:

Monoarticular: joint pain localized and involving only one joint Polyarticular: involving several joints Extra-articular joint pain: involves bones, muscles, and tissues around the joint such as the tendons, bursae, or even overlying skin

Extra-articular structures:

include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin Extra-articular disease: typically involves selected regions of the joint and types of movements

Articular structures:

include the joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone. -Articular cartilage: comprised of a collagen matrix containing charged ions and water, allowing cartilage to change shape in response to pressure or load (cushioning for underlying bone) -Synovial fluid: provides nutrition to adjacent avascular articular cartilage

Tendinitis, arthritis, bursitis and osteomyelitis

increased warmth

de Quervain's tenosynovitis and gonococcal tenosynovitis:

tenderness over extensor and abductor tendons of thumb at radial styloid

Gastrocnemius and Soleus muscles, achilles tendon:

-Palpate gastrocnemius and soleus on posterior surface of lower leg. Achilles tendon is palpable too from about the lower third of calf to its insertion on calcaneus -Test integrity of Achilles tendon: place pt prone with knee and ankle flexed at 90 degrees, or ask pt to kneel on a chair. Squeeze calf and watch for plantar flexion at the ankle: -Absence of plantar flexion=positive test indicating rupture of Achilles tendon. Sudden severe pain ("like a gunshot wound"), ecchymosis from calf into heel, and flat footed gait with absence of "toe off" may also be present

Risk factors for osteoporosis:

-Prior fragility fracture -Postmenopausal status in women -Age >50 years -Weight <154 lbs (70 kgs) -Low dietary calcium -Vitamin D deficiency -Tobacco and alcohol use -Family history of fracture in a first degree relative -Use of corticosteroids -Medical conditions such as thyrotoxicosis, celiac sprue, chronic renal disease, organ transplantation, diabetes, HIV, primary or secondary hypogonadism, multiple myeloma, anorexia nervosa -Medications such as aromatase inhibitors for breast cancer, methotrexate, selected antiseizure meds, immunosuppressive agents, and antigonadal therapy -Inflammatory disorders of the MSK, pulm, or gastro systems including rheumatoid arthritis

Osteoporosis:

-Systemic skeletal condition characterized by low bone mass and microarchitectural deterioration of bone tissues that increases bone fragility and risk for fractures -Calcium and Vitamin D important Osteoporosis: T score <2-2.5 Osteopenia: T score -2.5-1.5

The SPINE:

-Vertebrae and intervertebral discs -Interconnecting system of ligaments between anterior vertebrae and posterior vertebrae, ligaments between spinous processes, ligaments betwen lamina of 2 adjacent vertebrae Functions: joint articulations, weight bearing, muscle attachments, foramina for spinal nerve roots and peripheral nerves Vertebral body: anteriorly supports weight bearing Vertebral arch: posteriorly encloses the spinal cord Spinous process: projects posteriorly in midline and 2 transverse processes at the junction of pedicle and lamina. Muscles attach here -Articular processes: 2 on each side of vertebra, one facing up and one down, at the junction of pedicles and laminae (articular facets) -Vertebral foramen: enclose spinal cord -Intervertebral foramen: formed by inferior and superior articulating process of adjacent vertebrae (channel created for spinal nerve roots); cervical vertebrae the transverse foramen for vertebral artery NOTE: because spinal cord and nerve roots are so close to their bony vertebral casing and intervertebral discs: especially vulnerable to disc herniation, impingement (degenerative changes), trauma

THE WRIST AND HANDS:

-Wrist: distal radius and ulna, and 8 carpal bones JOINTS: 1) Wrist joints: radiocarpal, distal radioulnar, and intercarpal joints -Joint capsule, articular disc, synovial membrane join the radius to the ulna AND to the carpal bones -Radiocarpal joint: dorsum of the wrist: provides most of flexion and extension at wrist b/c the ulna does not articular directly with carpal bones 2) Hand joints: -Metacarpophalangeal joints (MCPs) -Proximal interphalangeal joints (PIPs) -DIstal interphalangeal joints (DIPs)

Knee movement findings:

-tenderness over tendon or inability to extend knee: partial or complete tear of patellar tendon -Pain/crepitus: roughening of patellar undersurface that articulates with femur -Pain with compression/patellar movement during quad contraction: chondromalacia, or degenerative patella (patellofemoral syndrome) -Swelling above and adjacent to patella=synovial thickening or effusion in knee joint Suprapatellar pouch, prepatellar bursa, anserine bursa: -Palpate any thickening/swelling (note: thickening, bogginess or warmth in these areas indicates synovitis or nontender effusions from osteoarthritis) -Also palpate popliteal fossa on posterior surface with leg extended

Palpation tests for effusion in knee joint

1) Bulge sign (for minor effusions): with knee extended, place left hand above knee and apply pressure on suprapatellar pouch, displacing fluid downward. Stroke downward on medial aspect of knee and apply pressure to force fluid into lateral area. Tap knee just behind lateral margin of patella with right hand -A fluid wave or bulge on medial side between patella and femur: positive sign =effusion 2) Ballon sign (for major effusions): place thumb and index finger of right hand on each side of patella; with left hand compress suprapatellar pouch against femur. FEel for fluid entering (ballooning into) spaces next to patella under right thumb and index finger -Palpable fluid wave =positive. Returning fluid wave into suprapatellar pouch confirms effusion 3) Balloting the patella: to assess large effusions--compress suprapatellar pouch and "ballotte" or push patella sharply against femur. Watch for fluid returning to suprapatellar pouch. -Palpable fluid returning into pouch further confirms large effusion

Tips for successful exam of MSK system:

1) During inspection, look for symmetry of involvement. Is the change in joints symmetric on both sides of the body, or is the change only in one or two joints? 2)Note any deformities or malalignment of bones or joints 3) Use inspection and palpation to assess surrounding tissues, noting skin changes/nodules/muscle atrophy. Note crepitus (audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss) 4) Test range of motion (described for each joint) to demonstrate limitations in range of motion or joint stability from excess mobility of joint ligaments, (ligamentous laxity) 5) Test muscle strength to aid in assessment of joint function

Three joints at shoulder:

1) GH Joint: head of humerus articulates with glenoid fossa of scapula -Ball and socket: allowing the arm wide arc of movement: flex/extension; abduction/adduction; rotation; circumduction 2) Sternoclavicular cjoint: medial end of clavicle articulates with upper sternum 3) Acromioclavicular joint: lateral end of clavicle articulates with acromion process of scapula

Steps for examining the joints:

1) Inspect for joint symmetry, alignment, bony deformities and swelling 2) Inspect and palpate surrounding tissues for skin changes, nodules, muscle atrophy, tenderness 3) Assess range of motion and maneuvers to test joint function and stability and the integrity of ligaments, tendons, bursae, esp if pain or trauma 4) Assess any areas of inflammation, esp tenderness, swelling, warmth, redness

MSK Exam:

1) Inspection 2) Palpation 3) ROM 4) Strength testing 5) Integrated testing 6) Special tests

Techniques of examination of shoulder:

1) Inspection: observe shoulder and shoulder girdle anteriorly, and inspect scapulae and related muscles posteriorly -Note swelling, deformity, muscle atrophy or fasciculations, or abnormal positioning -look for swelling of joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Look for color change, skin alteration, unusual bony contours Palpation: palpate bony structures of shoulder and any area of pain -Begin medially, at sternoclavicular joint, tracing clavicle laterally with fingers -From behind, follow bony spine of scapula laterally and upward until it becomes the acromion (summit of shoulder) -Locate acriomioclavicular joint and move thumb medially and down-- the coracoid process of the scapula -Palpate greater tubercle -Palpate biceps tendon (intertubercular groove), checking for tendon tenderness. Can rotate GH joint externally, locate muscle near elbow, and track muscle and tendon proximally into the groove -Examine subacromial and subdeltoid bursae and SITS muscles: extend humerus by lifting elbow posteriorly (causes rotation of these muscles); then palpate -Palpate capsule and synovial membrane to check for injury or arthritis

Muscles of mastication:

1) Masseters, externally at the angle of the mandible 2) Temporal muscles: externally during clenching and relaxation of jaw 3) Pterygoid muscles: internally between tonsillar pillars at the mandible

Special techniques:

1) Measuring the length of legs: get the pt relaxed in supine position and symmetrically aligned with legs extended -With tape measure, measure distance between anterior superior iliac spine and medial malleolus -Tape should cross knee on its medial side Note: unequal leg length likely for scoliosis 2) Describing limited motion of a joint: measure motion of pt's joints using goniometer (in degrees)

Important aspects for health promotion and counseling:

1) Nutrition, weight, physical acitvity (current guidelines: 2.5 hours of moderate intensity or 1 hour and 15 min vigorous PLUS moderate or high intensity strength training 2 or more days a week) 2) Profiling low back pain (one of most important outcome predictors is depression, which doubles the incidence of new low back pain in asymptomatic patients) -Other predictors persisting to 1 year: maladaptive pain related to fear of movements to worsen it (leading to avoidance of work/movement/etc); high somatization scores; poor general health; high levels of baseline functional impairment; prior history of chronic or low back pain 3) Osteoporosis: screening and prevention -1/2 of all post menopausal women sustain osteoporosis-related fracture; 1/4 men over 50 years has one 4) Preventing falls: leading cause of nonfatal injuries and prompt a dramatic rise in death rates over 65 years

Muscle groups at shoulder:

1) Scapulohumeral group: extends from scapula to humerus, includes: -Supraspinatus: above GH joint and inserts on greater tubercle -Infraspinatus and teres minor: cross GH joint posteriorly and insert on greater tubercle -Subscapularis: anterior surface of scapula and crosses GH joint; inserts lesser tubercle FUNCTION: rotates shoulder laterally and depresses and rotates the head of the humerus 2) Axioscapular Group: attaches the trunk to the scapula -Trapezius, rhombus, serratus anterior, levator scapula FUNCTION: rotate scapula 3) Axiohumeral group: attaches the trunk to the humerus -Includes: Pectoralis major, Pectoralis minor, Latissimus dorsi FUNCTION: internal rotation of shoulder NOTE: Biceps and triceps (Connect scapula to bones of the forearm) help with forward flexion (biceps) and extension (triceps)

Assessing the four signs of inflammation:

1) Swelling: palpable swelling may involve: 1) the synovial membrane, which can feel boggy or doughy; 2) effusion from excess synovial fluid within the joint space; 3) soft tissue structures (bursae, tendons, and tendon sheaths) 2) Warmth:compare involved joints with unaffected contralateral joint, or with nearby tissues if both joints are involved 3) Redness: redness of overlying skin is the least common sign of inflammation near the joints and is usually seen in more superficial joints like fingers, toes, knees 4) Pain or tenderness; try to identify the specific anatomic structure that is tender NOTE: diffuse tenderness and warmth over a thickened synovium suggest arhtritis or infection; focal tenderness suggests injury and trauma

Types of joint articulation:

1) Synovial: freely movable -Ex: knee, shoulder *Bones are covered by articular cartilage and separated by a synovial cavity to cushion joint movement *A synovial membrane lines the synovial cavity, secreting synovial fluid *Joint capsule: surrounds the joint and is strengthened by ligaments *Bones do not touch (fully moveable) Cartilaginous: slightly moveable -ex: vertebral bodies of the spine; symphysis pubis *Fibrocartilaginous discs separate the bony surfaces; at the center of each disc is the nucleus pulposus (cushion/shock absorber) Fibrous: immovable -ex: skull structures *firbous tissue or cartilage hold bones together; almost in direct contact (not moveable)

Prevalence of MSK problems:

7.9% of all ambulatory care visits are MSK 3 of the top 10 ambulatory diagnoses are msk related. Arthritis alone affects 1/5 Americans (19%) of the population, and is the leading cause of disability -Back and spine affects 17% of Americans -Low back pain=the 5th ranked most frequent reason for office visits TOP 3: Low back pain; osteoarthritis; fibromyalgia

Monoarticular or Polyarticular Joint Pain:

Ask: "do you have any pains in your joints?" -Ask them to point to the pain -If the joint pain is localized and involves only one joint: monoarticular -If joint is polyarticular, what is the pattern of involvement? Migrating from joint to joint or steadily spreading from one joint to multiple joints?Is the involvement symmetric, affecting similar joints on both side of the body? -TIMING: assess chronicity, quality, severity of joint symptoms. Did it develop over several hours or weeks or months? Has it progressed slowly or fluctuated? How long has it lasted? What is it like over a course of the day (morning vs night)? -If more rapid in onset:how did it arise? was there acute injury or overuse from repetitive motion? If from trauma what was the mechanism of injury? What aggravates/alleviates pain? What are the effects of exercise, rest, treatment? -INFLAMMATION: is the problem inflammatory or noninflammatory? Is there tenderness, warmth, redness? Ask about systemic symptoms such as fever or chills -SWELLING/STIFFNESS: localize any swelling as accurately as possible; if stiffness is present, clarify: MSK stiffness is a perceived tightness or resistance to movement and is associated with discomfort or pain often. -Find out when the pt gets up in the morning and when the joints feel most limber; healthy people experience stiffness and muscular soreness after strenuous exercise -LIMITATIONS OF MOTION: ask about changes in level of activity due to these problems with the joint. Inquire about ability to walk, stand, lean over, sit, rise from sitting position, climb, pinch, grasp, open door handle, daily activities: combing hair/brushing teeth/eating/dressing/bathing -SYSTEMIC FEATURES: fever, chills, rash, anorexia, weight loss, weakness Note: pain in one joint suggests injury, monoarticular arthritis, possible tendinitis, or bursitis.

For midline back pain:

Assess for musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metastases, and rarely epidural abscess. For pain off the midline: assess for muscle strain, sacroiilitis, trochanter bursitis,sciatica, and hip arthritis; also for renal conditions like pyelonephritis or stones

Carpal tunnel:

Beneath palmar surface of wrist and proximal hand: contains the sheath and flexor tendons of the forearm muscles and median nerve -Bound by carpal bones and flexor retinaculum (scaphoid/trapezium-->hook of hamate) -Contents: -fexor digitorum superficialis, profundus, flexor pollicis longus, and median nerve

If restricted range of motion occurs:

Bursitis, capsulitis, rotator cuff tears or sprains, and tendinitis

Extra-articular pain in the following conditions:

Bursitis; tendinitis; tenosynovitis; sprains from stretching or tearing of ligaments

Diffuse swelling vs local:

Diffuse swelling: common in arthritis or infection; local swelling suggests ganglion

Neurofibramatosis:

Cafe au lai spots (discolored patches of skin), skin tags, and fibrous tumors are common

Tendons:

Collagen fibers connecting muscle to bone

Knee:

Condylar/hinge joint -largest articulating surface of any joint! -Articulation between femur and tibia (tibiofemoral joint) -Weight bearing -Bones: femur, tibia, patella ACL - anterior restraint of translation of tibia on femur PCL - posterior restraint of translation of tibia on femur MCL - stabilizes medial joint line, checks valgus force LCL - stabilizes lateral joint line - checks varus force Medial/lateral meniscus - absorbs shock from axial loads, protect articular surfaces, stability

Tenderness over SITS muscle insertions and inability to abduct the arm above shoulder level:

Seen in sprains, tears, tendon rupture of rotator cuff (most commonly supraspinatus)

Range of motion and maneuvers for elbow:

Flexion: -Biceps brachii, brachialis, brachioradiais "Bend your elbow" Extension: triceps brachii, anconeus "Straighten your elbow" Supination: biceps brachii, supinator "Turn your palms up as if carrying a bowl of soup" Pronation: pronator teres, pronator quadratus "Turn your palms down"

Range of motion and maneuvers of Knee:

Flexion: (rectus femoris, vastus medialis, vastus lateralis, intermedius) "Bend or flex knee" or "squat down to floor" Extension: quadriceps hamstring group, biceps femoris, semitendinosus, semimembranosus "Straighten your leg" or "after you squat down to floor, stand up" Internal rotation: sartorius, gracilis, semiteninosus, semimembranosus "While sitting, swing your lower leg toward midline" External rotation: biceps femoris "While sitting, swing your lower leg away from midline" MANEUVERS: 1) McMurray Test: tests the medial and lateral meniscuses -With pt supine, grasp hell and flex the knee; cup other hand over hte knee joint with fingers and thumb along medial joint line. From heel, externally rotate the lower, then push on lateral side to apply valgus stress on medial side of joint. At same time, slowly extend lower leg in external rotation --Then same maneuver with internal rotation of foot stresses lateral meniscus **If click or pop along medial joint occurs with valgus stress/external rotation/leg extension--suggests probably tear of posterior portion of medial meniscus. -Note: the tear may displace meniscal tissue causing "locking" on full knee extension 2)Abduction (or valgus) stress test: tests the MCL: with the patient supine and knee slightly flexed, move thigh about 30 degrees laterally. Place one hand against lateral knee to stabilize femur and other around medial ankle. Push medially against knee and pull laterally at ankle to open knee joint on medial side (valgus stress) --Pain or a gap in medial joint line points to ligamentous laxity and partial tear of MCL 3) Adduction (or varus) stress test: tests LCL -with thigh and knee in same position, change my position to place on hand against medial surface of knee and other around the lateral ankle. Push laterally against the knee and pull medially at ankle ot open the knee joint on the lateral side (Varus stress) --Pain or gap in lateral joint line points to ligamentous laxity and partial tear of LCL 4) Anterior Drawer Sign: tests ACL: patient supine, hips flexed and knees flexed to 90 degrees and feet flat on table, cup hands around knee with thumbs on medial and lateral joint line and fingers on medial and lateral insertions of hamstrings. Draw tibia forward and observe if it slides forward (like a drawer) from under the femur. Compare the degree of forward movement with that of opposite knee. -Forward jerk showing contours of upper tibia=positive anterior drawer sign: making an ACL tear 11.5x more likely -ACL injuries occur with hyperextension and direct blows to the knee and with twisting or landing on an extended hip or knee 5) Lachman Test: tests ACL: place knee in 15 degrees of flexion and external rotation. Grasp distal femur on lateral side with one hand and proximal tibia on medial side with other. With thumb of tibial hand on joint line, simultaneously pull tibia forward and femur back. Estimate degree of forward excursion -Sig forward excursion indicates an ACL tear (likelihood increases by 17x if positive test) 6) Posterior Drawer Sign. Tests PCL: position pt and place hands in positions described for anterior drawer test. Push tibia posteriorly and observe the degree of backward movement in the femur --If PCL is injured, the proximal tibia falls back, a positive posterior drawer sign --Isolated PCL tears are less common, usually resulting from direct blow to proximal tibia

Cauda equina syndrome:

From s2-4 midline disc or tumor if there is bowel or bladder dysfunction(usually urinary retention with overflow incontinence), esp if there is saddle anesthesia or perineal numbness

THE ELBOW:

Function: helps position hand in space and stabilizes lever action of the forearm -Formed by: humerus, the radius and the ulna -Three articulations: humeroulnar joint, radiohumeral joint, radioulnar joint -Muscles: biceps, brachioradialis (flexion), brachialis, triceps (extension), pronator teres (pronation), supinator (supination) -Olecranon bursa is located between olecranon process and skin (only palpable when inflamed and swollen) -ULnar nerve runs posteriorly in the ulnar groove between medial epicondyle and olecranon process -Radial nerve is adjacent to lateral epicondyle -Median nerve is medial to brachial artery in the antecubital fossa (ventral arm)

The SHOULDER: OVERVIEW

GH JOINT: wide range movement in all directions: humeral head contacts <1/3 of the surface area of the glenoid fossa (dangling from the scapula) Shoulder girdle: the four joints, three large bones, and three principle muscle groups that give the shoulder its mobility Dynamic stabilizers: Supraspinatus, infraspinatus, teres minor, and subscapularis. Move the humerus and compress/stabilize the humeral head within the glenoid cavity Static stabilizers: bony structures of the shoulder girdle, the labrum, the articular capsule, and GH ligaments. -Labrum: fibrocartilaginous ring that surrounds the glenoid and deepends its socket, providing greater stability to the humeral head -The joint capsule =strengthened by tendons of rotator cuff and GH ligaments, adding to joint stability

THE KNEE:

Hinge joint: femur, tibia, patella (kneecap) -Three articular surfaces: one between femur and patella, 2 between femur and tibia -Dependent completely on the 4 ligaments to hold it and femur/tibia in place; lack of padding; lever action ^^Highly vulnerable to injury therefore Medial surface: -adductor tubercle, medial epicondyle of femur; medial condyle of tibia Anterior surface: -patella, patellar tendon (inserts on tibial tuberosity) Lateral surface: -lateral epicondyle of femur, lateral condyle of tibia, head of fibula JOINTS: -2 condylar tibiofemoral joints: form from articulation of medial/lateral condyles of femur on condlyes of tibia -Patellofemoral joint: slides on the trochlear groove during flexion/extension of knee MUSCLES: -Quadriceps femoris: extend the knee (rectur femoris, vastus lateralis, vastus medialis) -Hamstring muscles: flex the knee (semimembranosus, gracilis, sartorius, semitendinosus) Additional structures: -Medial and lateral menisci: cushion femur on tibia -Medial collateral ligament (MCL): connects medial femoral epicondyle to medial condyle of tibia -Lateral collateral ligament (LCL): connects lateral femoral epicondyle to head of fibula. *Together MCL and LCL provide medial and lateral stability to knee joint -Anterior cruciate ligament (ACL): crosses from anterior medial tibia to lateral femoral condyle obliquely--prevents tibia from sliding forward on femu -Posterior cruciate ligament (PCL): posterior tibia/lateral meniscus-->medial femoral condyle; prevents tibia from slipping backward on femur -Synovial cavity of knee: largest joint cavity in the body **Not normally palpable, but with inflammation the synovium may get swollen and tender/palpable -Prepatellar bursa: between patella and skin -Anserine bursa: below knee joint medially -Semimembranosus bursa: communicates with joint cavity (posterior and medial surfaces of knee)

PRepatellar bursitis

Housemaid's knee -Arises from excessive kneeling

Techniques of examination of elbow joint:

INSPECTION: Support forearm so elbow is flexed at 70 degrees for inspection PALPATION: palpate olecranon process, press over the epicondyles for tenderness/effusion -Note any displacement of olecranon -Palpate grooves between epicondyles and olecranon process to feel synovium most easily. Normally, cannot palpate synovium or olecranon bursa -Ulnar nerve can be felt posteriorly between olecranon process and medial epicondyle

Subacromial bursitis:

If the bursal surfaces are inflamed, may be tenderness just below the tip of the acromion, pain with abduction and rotation, and loss of smooth movement

Antiresorptive agents:

Inhibit osteoclast activity and slow bone remodeling, allowing better mineralization of bone matrix and stabilization of the trabecular microarchitecture. -Bisphosphonates, selective estrogen receptor modulators (SERMs), calcitonin, postmenopausal estrogen

GAIT inspection: HIP

Inspect two phases of gait: 1) Swing (foot moves forward, non weight bearing) 2) Stance (foot on ground, weight bearing) **Assess width of base (2-4 inch, heel to heel), shift of pelvis (smooth and continuous), flexion of the knee (flexed throughout stance phase) Inspect anterior/posterior surfaces of the hip for muscle atrophy or bruising Look for: -Limp -Width of base (normal or wide) Note: neurological is pathological and leads to a WIDE base of walking

TECHNIQUES for exam: KNEE

Inspection: gait, alignment/contours of knee; observe for atrophy of quad muscles -Look for loss of normal hollows around patella (sign of swelling in knee joint/suprapatellar pouch) Palpation: -Tibiofemoral joint: place thumbs in soft tissue depressions on either side of patellar tendon. Identify tibiofemoral joint groove---follow articulating surface of femur to feel joint margins. Note any irregular bony ridges along joint margins -Medial meniscus: easier to palpate if tibia is slightly internally rotated: press on medial soft tissue depression along upper edge of tibial plateau -Lateral meniscus: place knee in slight flexion to palpate along lateral joint line -Medial and lateral joint compartments: of tibiofemoral joint with knee flexed on table to 90 degrees -Medial compartment: move thumbs upward to palpate medial femoral condyle; adductor tubercle is posterior to medial femoral condyle; move thumbs down to palpate medial tibial plateau -Medial collateral lig: palpate from medial epicondyle of femur to medial condyle/superior medial surface of tibia (NOTE: MCL tenderness after injury is suspicious of an MCL tear) -Lateral compartment: lateral femoral condyle and lateral tibial plateau. When knee is flexed--femoral epicondyles are lateral to femoral condyles -Have pt cross one leg so ankle rests on opposite knee: lateral collateral lig: from lateral femoral epicondyle to head of fibula -Patellofemoral compartment: locate patella and trace patellar tendon distally until palpate tibial tuberosity: ask pt to extend knee to make sure patellar tendon is intact -With pt supine and knee extended: compress patella against femur, move it medially and laterally assessing for crepitus and pain. Ask pt to tighten quads as patella moves distally in trochlear groove. Check for smooth slighting motion (patellofemoral grinding test)

Techniques of exam: Ankle and Foot:

Inspection: observe all surfaces of ankles and feet, noting deformities, nodules, swelling, calluses, or corns Palpation: with thumbs palpate anterior aspect of each ankle joint, noting bogginess, swelling, or tenderness -Feel along Achilles tendon for nodules and tenderness -Palpate the heel, esp posterior and inferior calcaneus, and plantar fascia for tenderness -Palpate for tenderness over medial and lateral malleolus, esp in cases of trauma -Palpate metatarsophalangeal joints for tenderness: compress forefoot between thumb and fingers. Exert pressure just proximal to the heads of the first and fifth metatarsals -Palpate the heads of the five metatarsals and the grooves between them with thumb and index finger. Place thumb on the dorsum of the foot and index finger on plantar surface

Techniques of examination of wrist and hands:

Inspection: observe position of hands in motion to see if movements are smooth/natural. When fingers are relaxed, should be slightly flexed; fingernail edges should be in parallel -Inspect palmar and dorsal surfaces for swelling over joints -Note deformities or angulation -Observe contours of the palm -Note any thickening of flexor tendons or flexion contractures in fingers PALPATION: -Papate distal radius and ulna on lateral and medial surfaces; palpate groove of each wrist joint with thumbs on dorsum of wrist and fingers beneath it. Note swelling, bogginess, or tenderness -Palpate radial styloid bone and anatomical snuffbox -Palpate carpal bones lying distal to wrist joint, and then the metacarpals and phalanges -Compress MCP joints by squeezing hand from each side between thumb and fingers; use thumb to palpate each MCP joint. Note swelling, bogginess, tenderness (synovitis here is painful to pressure) -Examine fingers and thumb. Palpate medial and lateral aspects of each PIP joint between thumb and index finger; again checking for swelling, bogginess, bony enlargement, or tenderness -Examine DIP joints with same techniques -Palpate along tendons inserting on thumb and fingers any area of swelling/inflammation

Techniques of examination SPINE:

Inspection: observe pt's posture -smooth coordinated neck movement, ease of gait -when pt stands: head should be midline in same plane as sacrum and shoulders/pelvis should be level -Posterior view: identify: spinous processes, paravertebral muscles on either side of midline, iliac crests, posterior superior iliac spines -Evaluate spine curvatures Palpation: -palpate spinous processes of each vertebra with thumb -Neck: palpate facet joints between cervical vertebrae (lateral to spinous processes). May only be palpable when neck is relaxed -Lower lumbar area: check for vertebral step offs to determine whether one spinous process seems prominent in relation to others. Identify tenderness -Palpate over sacroiliac joint -Percuss spine for tenderness by thumbing with ulnar surface of fist (pain from this may be osteoporosis, infection, malignancy) -Inspect/palpate paravertebral muscles for tenderness and spasm. Muscles in spasm feel firm and knotted and may be visible. -Palpate sciatic nerve (hip flexed and pt lying on opposite side) (tenderness here suggests herniated disc or mass lesion impinging on nerve roots) -Low back pain warrants careful assessment for cauda equina compression (b/c of risk of paralysis of affected limb or loss of bladder or bowel control)

Articular cartilage once injured:

Is replaced by less resilient fibrocartilage, increasing risk of pain and osteoarthritis

First goal of evaluation of MSK disorders is to characterize the pt's complaint in terms of 4 key features:

Is the joint: 1) Articular or extra articular 2) Acute (usually <6 weeks) or chronic (usually >12 weeks)? 3) Inflammatory or noninflammatory? 4) Localized (monoarticular) or diffuse (polyarticular?)

Spine: Joints, muscle groups

Joints: -Cartilaginous joints: slightly moveable (between vertebral bodies and articular facets) -Intervertebral discs: cushion movements between vertebrae and allow vertebral column to curve, flex, bend -Flexibility: determined by angle of articular facet joints relative to plane of vertebral body (varies at different levels of spine) -Lumbosacral junction: vertebral column angles posteriorly here and becomes immovable: contributes to risk for disc herniation and subluxation Muscle groups: -Trapezius and lat dorsi: form outer layer of muscles attaching to each side of spine -Deeper muscle layers: 1) attaches to head, neck and spinous processes (splenius capitis, splenius cervicis, sacrospinalis) and smaller muscles between vertebrae -Muscles attaching to anterior surface of vertebrae: psoas muscle, muscles of abd wall (assist with flexion)

Scoliosis:

Lateral and rotatory curvature of spine to bring head back to midline -Unequal shoulder heights -Can cause pelvic tilt -NOTE: deformity of thorax on forward bending (esp differences in height of scapulae)=likely this

Spinal stenosis

Leg pain that resolves with rest and or lumbar forward flexion occurs

Palpation and inspection problems foot and ankle:

Localized tenderness: often present in arthritis, ligamentous injury, or infection of the ankle -Rheumatoid nodules and tenderness: found in Achilles tendinitis,bursitis, or partial tear from trauma -Bone spurs: may be present on calcaneus -focal heel tenderness on palpation of plantar fascia=plantar fasciitis, seen in prolonged standing or heel strike exercise and in rheumatoid arthritis or gout -Tenderness along posterior medial malleolus: suggests posterior tibial tendinitis and causes flat feet Tenderness on compression: early sign of rheumatoid arthritis -Acute inflammation of first mettarsophalangeal joint suggests gout Pain and tenderness (metatarsalgia): occurs in trauma, arthritis, vascular compromise Tenderness over 3rd and 4th metatarsal heads on plantar surface: Morton's neuroma Forefoot abnormalities (hallux valgus, metatarsalgia, Morton's neuroma)=more common in women who wear high heeled shoes with narrow toe boxes

ANKLE AND FOOT:

Must balance the body and absorb the impact of the heel strike and gait. Therefore frequent sites of sprain and bone injury Ankle: -Hinge joint formed by tibia, fibula, talus Principle joints here: 1) Tibiotalar joint (between tibia and talus) 2) Subtalar (talocalcaneal) joint Medial malleolus: bony prominence at distal end of tibia Lateral malleolus: distal end of fibula Calcaneus: heel bone Longitudinal arch: imaginary line that spans the foot, extending from calcaneus of hind foot along tarsal bones of midfoot to forefoot metatarsal and toes Heads of metatarsals: palpable in the ball of the foot Metatarsophalangeal joints: forefoot, proximal to web of toes Proximal and distal interphalangeal joints: more distal

If no sign of arthritis, "aches and pains" are called

Myalgias in muscles Arthralgias if pain in joints but no evidence of arthritis

RANGE OF MOTION and maneuvers: SPINE

Neck: Flexion/extension (skull-->C1); rotation (C1-C2 and axis); lateral bending (C2-C7) (NOTE: limitations in motion here can be arthritis, pain from trauma, overuse or muscle spasm=torticollis) Flexion: sternocleidomastoid, scalene, prevertebral muscles "Bring chin to chest" Extension: splenius capitis and cervitis, small intrinsic neck muscles "look up at ceiling" Rotation: sternocleidomastoid, small intrinsic neck muscles "Look over one shoulder and then the other" Lateral bending: Scalenes, small intrinsic neck muscles "Bring ear to shoulder" NOTE: any tenderness/loss of sensation/weakness=neurological testing needed of neck and UE (Tenderness at C1-C2 in rheumatoid arhtritis=risk for subluxation and cervical cord compression) SPINAL COLUMN: Flexion: Psoas major and minor, quadratus lumborum, abdominal muscles attached to anterior vertebrae (internal and external obliques, rectus abdominis) "Bend forward and try to touch toes"--note smoothness, symmetry, ROM, curve Extension: deep intrinsic muscles of back (erector spinae and transversospinalis group) "Bend back as far as possible"--support pt by placing hand on posterior superior iliac spine Rotation: abdominal muscles, intrinsic muscles of back "Rotate from side to side"--one hand on pt's hip and other on opposite shoulder. Then rotate trunk by pullin shoulder anteriorly and hip posteriorly. Repeat on other side Lateral bending: abdominal muscles, intrinsic muscles of back "Bend to side from waist"--stabilize pt's pelvis by placing hand on pt's hip. Repeat for opposite side **Again: pain/tenderness=warrants neurologic testing of lower extremities

Shoulder maneuvers:

Neer impingement: compresses the greater tuberosity of humerus against acromion -Scapulothoracic stabilization -Pain=subacromial impingement/tendonitis Hawkins impingement: compresses the greater tuberosity against supraspinatus tendon and coracoacromial ligament -Pain with internal rotation = impingment/tendonitis Drop arm test: -Loss of control=RTC tear Empty can test: -Pain=supraspinatus tendonitis; weakness=tear

Peripheral nerve distribution of hand:

Note: Tingling in all fingers=generally benign; tingling in specific (not all) fingers=more likely to be something

Synovial joints more in depth:

Note: the shape of articulating surfaces of synovial joints and surrounding soft tissues determines the direction and extent of joint motion 1) Spheroidal (ball and socket): -Articular shape: convex surface in concave cavity -Movement: wide ranging flexion, extension, abduction, adduction, rotation, circumduction Ex: shoulder, hip 2) Hinge: -Articular shape: flat, planar -Movement: motion in one plane; flexion, extension Ex: interpahlangeal joints of hand and foot; elbow 3) Condylar: Articular shape: convex or concave -Movement of 2 articulating surfaces not dissociable. Allow flexion, extension, rotation and motion in the coronal plane Ex: Knee; temporomandibular joint

ACL laxity

Occurs in knee trauma

Olecranon bursitis and arthritis

Olecranon bursitis: swelling over the olecranon process Arthritis: inflammation or synovial fluid

Articular vs nonarticular pain way to tell:

Pain, swelling, loss of active and passive motion, or "locking" suggest articular joint pain Loss of active but not passive motion and tenderness outside the joint=nonarticular pain

Redness over a tender joint

Septic or crystalline arthritis, or possibly RA

Wrist: Range of motion and maneuvers

RANGE OF MOTION: -Flexion: flexor carpi radialis, flexor carpi ulnaris "With palms down, point fingers toward the floor" -Extension: extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis "With palms down, point fingers toward ceiling" -Adduction (radial deviation): flexor carpi ulnaris "With palms down, bring fingers toward midline" -Abduction (ulnar deviation): flexor carpi radialis "With palms facing down, bring fingers away from midline" CONDITIONS that impair these motions: arthritis, tenosynovitis, Dupuytren;s contracture MANEUVERS: 1) Test sensation as follows: pulp of the index finger (median nerve); pulp of the fifth finger (ulnar nerve0; dorsal web space of thumb and index finger (radial nerve) 2) Hand grip: have pt grasp second and third fingers of mine. Tests function of wrist joints, finger flexors, and intrinsic muscles and joints of hand -Decreased grip strength=positive test for weakness of these -Can also occur in de Quervain's, arthritis, carpal tunnel, cervil radiculopathy, epicondylitis 3) Thumb movement: test by asking pt to grasp the thumb against the palm and then move wrist toward midline in ulnar deviation (Finkelstein's test) -Pain=de Quervain's (inflammation of abductor pollicis longus and extensor pollicis brevis tendons and sheaths) 4) Carpal tunnel--thumb abduction, tinel's test, phalen's test: -Thumb abduction test by asking pt to raise the thumb straight up as you apply downward resistance -Tinel's sign for median nerve compression: tap lightly over course of median nerve in carpal tunnel (aching/numbness=positive median nerve issue) -Test Phalen's sign for median nerve compression: ask pt to hold wrists in flexion for 60 seconds; or press the backs of both hands together -Numbness and tingling=positive

Sciatica:

Radicular gluteal and posterior leg pain in the S1 distribution that increases with cough/Valsalva

Range of motion: Ankles and feet

Range of motion: Tibiotalar ankle joint: flexion/extension 1) Ankle flexion (plantar flexion): gastrocnemius, soleus, plantaris, tibialis posterior: "Point your foot toward the floor" 2) Ankle extension (dorsiflexion): tibialis anterior, extensor digitorum longus, extensor hallucis longus: "Point your foot toward the ceiling" Subtalar and transverse tarsal joints: 1) Inversion: Tibialis posterior and anterior: "Bend your heel inward" 2) Eversion: peroneus longus and brevis: "Bend your heel outward" MANEUVERS: 1) The ankle (tibiotalar) joint: dorsiflex and plantar flex the foot at the ankle (pain during movements of the ankle and foot help to localize possible arthritis) 2) Subtalar (talocalcaneal) joint: stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot by turning the heel inward then outward. (arthritic joint is painful when moved in any direction, while a ligamentous sprain produces maximal pain when the ligament is stretched) 3) Transverse tarsal joint: stabilize the heel and invert and evert the forefoot 4) Metatarsophalangeal joints: move the proximal phalanx of each toe up and down (pain suggests acute synovitis--instability occurs in chronic synovitis and claw toe deformity)

Checking Range of motion and maneuvers of shoulder joint:

Range of motion: -Flexion: anterior deltoid, pectoralis major, corachobrachialis, biceps brachii ("Raise your arms in front of you and overhead") -Extension: Lat dorsi, teres major, post deltoid, triceps brachii (long head) ("Raise your arms behind you") -Abduction: supraspinatus, middle delt, serratus anterior ("Raise your arms out to the side and overhead") NOTE: to test pure GH motion: should raise arms palm down to shoulder level at 90 degrees -to test pure scapulothoracic motion: should turn palms up and raise arms an additional 60 degrees -The last 30 degrees tests both these two combined -Adduction: pect major, corachobrachialis, lat dorsi, teres major, subscapularis ("Cross your arm in front of your body") -Internal rotation: subscapularis, anterior deltoid, pect major, teres major, latissimus dorsi ("Place one hand behind your back and touch your shoulder blade") -Identify highest midline spinous process pt can reach -External rotation: infraspinatus, teres minor, post deltoid ("Place one hand behind your neck as if you are brushing your hair") MANEUVERS: -Acriomioclavicular Joint: palpate and compare both joints for swelling or tenderness. Adduct pt's arm across chest "crossover test" -Overall shoulder rotation: Apley scratch test (ask pt to touch the opposite scapula using both overhand approach (testing abd and ext rotation) and underhand/behind back (tests add/int rotation) -Rotator cuff: 1) Test Neer's impingement sign: press on scapula to prevent scapular motion, and raise pt's arm with your other hand. Compresses the greater tuberosity of humerus against acromion -Pain=positive test, indicating possible inflammation or rotator cuff tear 2) Test Hawkin's impingement sign: flex patient's shoulder and elbow to 90 degrees with palm facing down. With one hand on forearm and one on arm, rotate the arm internally. Compresses the greater tuberosity against coracoacromial ligament -Pain=positive test; indicates possible inflammation or rotator cuff tear 3) Test supraspinatus strength: "empty can test" -Elevate the arms to 90 degrees and internally rotate the arms with thumbs pointing down (emptying a can); ask pt to resist as you place downward pressure on arms -Weakness=positive test; indicates possible rotator cuff tear 4) Test infraspinatus strength: ask pt to place arms at the side and flex elbows to 90 degrees with thumbs turned up. Provide resistance as the pt presses the forearms outward -Weakness=positive test; indicates poss rotator cuff tear or bicipital tendinitis 5) Test forearm supination: flex pt's forearm to 90 degrees at elbow and pronate pt's wrist. Provide resistance when pt supinates the forearm -Pain=positive; indicates inflammation of long head of biceps tendon and possible rotator cuff tear 6) Test the "drop arm" sign: ask pt to fully abduct arm to shoulder level (90 degrees), and lower it slowly. -If pt cannot hold arm fully abducted at shoulder level or cannot control lowering the arm, test=positive, indicates rotator cuff tear

Achilles ruptured tendon vs. tendinitis:

Ruptured Achilles tendon: defect in muscles with tenderness and swelling Tendinitis: tenderness and thickening of tendon above calcaneus, sometimes with bony process of calcaneus=Achilles tendinitis

Joint pain and systemic disorders:

SKin conditionss: -A butterfly rash on the cheeks (systemic lupus erythematosus) -The scaly rash and pitted nails of psoriasis (psoriatic arthritis) -A few papules, pustules, or vesicles on reddened bases, located on distal extremities (gonococcal arthritis) -An expanding erythematous patch early in an illness (Lyme disease) -Hives (serum sickness, drug reaction) -Erosions or scaling on penis and crusted, scaling papules on the soles and palms (Reiter's syndrome, includes arthritis/urethritis/uveitis) -The maculopapular rash of rubella (Arthritis of rubella) -Clubbing of the fingernails (Hypertrophic osteoarthropathy) -Red, burning, and itchy eyes=conjunctivitis (Reiter's syndrome, Behcet's syndrome) -Preceding sore throat: (Acute rheumatic fever or gonococcal arthritis) -Diarrhea, abd pain, cramping (Arthritis with ulcerative colitis, regional enteritis, scleroderma) -Symptoms of urethritis (Reiter's syndrome or possibly gonococcal arthritis) -Mental status change, facial or other weakness, stiff neck: (Lyme disease with central nervous system involvement)

Rheumatoid arthritis

Symmetric deformity in the PIP, MCP and wrist joints, and ulnar deviation -Note: swelling and or tenderness suggests this if bilateral and of several weeks' duration -Note: MCPs are often boggy or tender too -PIP changes are also seen

JOINTS:

Synovial: Joint is freely moveable -Bones are covered by articular cartilage -Bones are separated by synovial cavity -Synovial membrane secretes synovial fluid that lubricates joint movement -Ex: shoulder, knee Cartilaginous: -Joint is slightly moveable, bones separated by fibrocartilaginous discs -Discs contain nucleus pulposus that cushions bony movement Ex: vertebral bodies of the spine Fibrous joint: -Joints have no appreciable movement; bones separated by fibrous tissue or cartilage Ex: sutures of the skull SYNOVIAL JOINTS: Spheroidal (ball n socket): -Flex/ext, abd/add, rotate/circumduction -Shoulder, hip Hinge: -Flex/ext (one plane) -Interphalangeal joints of hand/foot; elbow Condylar: -Movement of Two articulating surfaces, not dissociable -Knee, TMJ

Ankle anatomy:

Talus: the bone that the tib/fib sits on Lateral malleolus: distal fibula Medial malleolus: distal tibia Medial ligaments: deltoid ligament Lateral ligaments: posterior and anterior talofibular ligaments, calcaneofibular ligament (between the two^) Ankle syndesmosis: fibrous joint formed by distal tibiofibular arcticulation -The ligament that holds the ankle together higher up (sprain here=syndesmosis injury)

Scaphoid fracture:

Tenderness over the snuffbox suggests this; the most common injury of the carpal bones -Poor blood supply puts the scaphoid bone at risk for avascular necrosis

Tennis elbow and pitcher/golfer's elbow

Tennis elbow: tenderness distal to the epicondyle=also called lateral epicondylitis Golfer or pitchers elbow: less common to have tenderness distal to epicondyle; also called medial epicondylitis NOTE: the olecranon is displaced posteriorly in posterior dislocation of elbow and supracondylar fracture

Assessing Joint Pain attributes of symptoms:

The 7 normal ones: -Onset -Location -Duration -Character (burning, sharp, etc) -Alleviating factors/aggravating ones -Radiation (associated manifestations in other systems) -Timing/duration -Severity AND -Ask the pt to point to the pain -Clarify and record when the pain started and the mechanism of injury, esp if there is history of trauma -Determine whether pain is localized or diffuse; acute or chronic; inflammatory or noninflammatory

Osteoarthritis:

look for Heberden's nodes at DIP joints and Bouchard's nodes at PIP joints -Likely when there are tender bony ridges along the joint margins, genu varum deformity, and stiffness lasting 30 mi n or less -Crepitus may be present

Synovitis:

palpable bogginess or doughiness of synovial membrane indicates this; which is often accompanied by effusion.. Palpable joint fluid is present in effusion, tenderness over the tendon sheaths in tendinitis

Bursae:

pouches of synovial fluid that cushion the movements of tendons and muscles over bone or other joint structures -Allow adjacent muscles or muscles and tendons to glide over each other during movement. They lie between the skin and convex surface of a bone or joint OR in areas where tendons or muscles rub against bone, ligaments, or other tendons or muscles

Carpal tunnel syndrome:

related to repetitive motion with wrists flexed (keyboard use, mail sorting), pregnancy, rheumatoid arthritis, diabetes, or hypothyroidism -Decreased sensation in median nerve distribution

Ligaments:

ropelike bundles of collagen fibrils that connect bone to bone (think "l" is like to like, so bone to bone)

Long head of biceps:

runs in groove (interterbular) between greater and lesser tubercles

Look for:

subcutaneous nodules in RA (also see muscle atrophy and weakness in RA) or rheumatic fever; effusion in trauma; crepitus over inflamed joints in OA or over the inflamed tendon sheaths of tenosynovitis

Tenderness of spine:

suggests fracture or dislocation if preceded by trauma, underlying infection or arthritis

Lateral hip pain near the greater trochanter

suggests trochanteric bursitis

Tenderness and effusion suggests:

synovitis of GH joint -If the margins of the capsule and synovial membrane are palpable, a moderate-->large effusion is present; if synovitis is minimal, it cannot be detected on palpation