Ch. 16 Musculoskeletal

Morton Neuroma

Look for tenderness over the plantar surface between the third and fourth metatarsal heads, from perineural fibrosis of the common digital nerve due to repetitive nerve irritation (not a true neuroma). Check for pain radiating to the toes when you press on the plantar interspace and squeeze the metatarsals with your other hand. Symptoms include hyperesthesia, numbness, aching, and burning from the metatarsal heads into the third and fourth toes.

Lumbar spinal Stenosis

Physical Signs : posture may be flexed forward to reduce symptoms with lower extremity weakness and hyporeflexia. Thigh pain typically occurs after 30 s of lumbar extension. Straight-leg raise is usually negative.

Rotator Cuff Tendinitis (Impingement syndrome)

Repeated shoulder motion for example from throwing or swimming can cause edema and hemorrhage followed by inflammation most commonly involving the supraspinatus tendon. Acute recurrent or chronic pain may result often aggravated by activity. Patients report sharp catches of pain grating, and weakness when lifting the arm overhead. When the supraspinatus tendon is involved tenderness is maximal just below the tip of the acromion. In older adults bone spurs on the undersurface of the acromion may contribute to symptoms.

Cervical Radiculopathy-from Nerve Root Compression

Sharp burning or tingling pain in the neck and one arm with associated paresthesias and weakness. Sensory symptoms often in myotomal pattern deep in muscle rather than dermatomal pattern.

Pain Referred from the Abdomen or Pelvis

Usually a deep aching pain- the level varies with the source. Accounts for-2% of low back pain.

Neuropathic Ulcer

When pain sensation is diminished or absent, as in diabetic neuropathy, neuropathic ulcers may develop at pressure points on the feet. Although often deep, infected, and indolent, they are painless. Underlying osteomyelitis and amputation may ensue. Early detection of loss of sensation using a nylon filament is the standard of care in diabetes.

Arthritis of the Elbow

%novial inflammation or fluid is felt best in the grooves between the olecranon process and the epicondyles on either side, Palpate for a boggy* soft or fluctuant swelling and for tenderness. Causes include RA gout and pseudogout, osteoarthritis, and trauma. Patients report pain, stiffness, and restricted motion,

Plantar Wart

A plantar wart is a hyperkeratotic lesion caused by human papillomavirus located on the sole of the foot. It may look like a callus. Look for the characteristic small dark spots that give a stippled appearance to a wart, Normal skin lines stop at the wart's edge. It is tender if pinched side to side, whereas a callus is tender to direct pressure.

Acute Gouty Arthritis

The metatarsophalangeal joint of the great toe is the initial site of attack in 50% of the episodes of acute gouty arthritis. It is characterized by a very painful and tender hot dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for a cellulitis, The ankle tarsal joints, and knee are also commonly involved.

Chronic Tophaceous Gout

Urate crystal deposits often with surrounding inflammation, cause deformities in subcutaneous tissues, bursae cartilage and subchondral bone that mimic RA and OA. Joint involvement is usually less symmetric than in RA. Acute inflammation may be present. Knobby swellings around the joints ulcerate and discharge white chalk-like urates.

Hammer Toe

Usually involving the second toe, a hammer toe is characterized by hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal (PIP) joint. A com frequently develops at the pressure point over the PIP joint,

Pain Referred from the Abdomen or Pelvis

Variable with the source. Local vertebral tenderness may be present. Spinal movements are not painful and range of motion is not affected. Look for signs of the primary disorder.

Calcific Tendinitis

Calcific tendinitis is a degenerative process in the tendon associated with the deposition of calcium salts that usually involves the supraspinatus tendon. Acute disabling attacks of shoulder pain ma/ occur, usually in patients ages >30 yrs, especially in women. The arm is held close to the side, and all motions are severely limited by pain. Tenderness is maximal below the tip of the acromion. The subacromial bursa, which overlies the supraspinatus tendon, may be inflamed. Chronic less severe pain may also occur.

Ganglion

Ganglia are cystic round usually nontender swellings along tendon sheaths or joint capsules frequently at the dorsum of the wrist. The cyst contains synovial fluid arising from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic cavity. Flexion of the wrist makes ganglia more prominent- extension tends to obscure them. Ganglia may also develop on the hands wrists ankles and feet. They can disappear spontaneously.

Osteoarthritis (Degenerative Joint Disease)

Heberden nodes on the dorsolateral aspects of the DIP joints from bony overgrowth of OA. Usually hard and painless, they affect middle-ages or older adults; they are often associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Bouchard nodes on the PIP joints are less common. The MCP joints are spared.

Acute Tenosynovitis and Thenar Space Involvement

If the infection progresses it may extend from the tendon sheath into the adjacent fascial spaces within the palm. Infections of the index finger and thenar space are illustrated- Early diagnosis and treatment are important.

Chronic Rheumatoid Arthritis

In chronic disease, note the swelling and thickening of the MCP and PIP joints. Range of motion becomes limited and fingers may deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show "swan neck" deformities (hyperextension of the PIP joints with fixed flexion of the distal interphalangeal [DIP] joints). Less common is a boutonniere deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). Rheumatoid nodules are seen in the acute or the chronic stage.

Hallux Valgus

In hallux valgus there is lateral deviation of the great toe and enlargement of the head of the first metatarsal on its medial side, forming a bursa or bunion. This bursa may become inflamed. Women are 10 times more likely to be affected than men.

Acute Tenosynovitis

Inflammation of the flexor tendon sheaths acute tenosynovitis, may follow local injury, overuse or infection. Unlike arthritis, tenderness and swelling develop not in the joint but along the course of the tendon sheath from the distal phalanx to the level of the metacarpophalangeal joint. The finger is held in slight flexion; finger extension is very painful- Causative infectious agents include Staphylococcus and Streptococcus species, disseminated gonorrhea, and Candida albicans.

Bicipital Tendinitis

Inflammation of the long head of the biceps tendon and tendon sheath causes anterior shoulder pain resembling and often coexisting with rotator cuff tendinitis. Both conditions may involve impingement injury. Tenderness is maximal in the bicipital groove. Externally rotate and abduct the arm to separate this area from the subacromial tenderness of supraspinatus tendinitis. With the patient's arm at the side, elbow flexed to 90°, ask the patient to supinate the forearm against your resistance. Increased pain in the bicipital groove confirms this condition. Pain during resisted forward flexion of the shoulder with the elbow extended is also characteristic.

Felon

Injury to the fingertip may result in infection of the enclosed fascial spaces of the distal pulp or phalanx pad of the fingertip, usually from Staphylococcus aureus. Severe pain localized tenderness swelling, and dusky redness are characteristics. Early diagnosis and treatment, usually incision and drainage, are important for preventing abscess formation. If vesicles are present. consider herpetic whitlow instead usually seen in health care workers exposed to herpes simplex virus in human saliva.

Epicondylitis

Lateral epicondylitis (tennis elbow) follows repetitive extension of the wrist or pronation-supination of the forearm. Pain and tenderness develop 1 cm distal to the lateral epicondyle and possibly in the extensor muscles close to it. When the patient tries to extend the wrist against resistance pain increases. Medial epicondylitis (pitcher's golfer's, or Little League elbow) follows repetitive wrist flexion such as throwing. Tenderness is maximal just lateral and distal to the medial epicondyle. Wrist flexion against resistance increases the pain

Callus

Like a com, a callus is an area of greatly thickened skin that develops in a region of recurrent pressure. Unlike a com a callus involves skin that is normally thick, such as the sole, and is usually painless. If a callus is painful, suspect an underlying plantar wart.

Mechanical Neck Pain-Whiplash

Mechanical neck pain with aching paracervical pain and stiffness, often beginning the day after injury. Occipital headache, dizziness, malaise, and fatigue may be present. Chronic whiplash syndrome if symptoms last more chan 6 mo- occurs in 20%-40% of injuries.

Cervical Myelopathv-from Cervical Cord Compression

Neck pain with bilateral weakness and paresthesias in both upper and lower extremities, often with urinary frequency Hand clumsiness palmar paresthesias and gait changes may be subtle. Neck flexion often exacerbates symptoms.

Cervical Radiculooathy-from Nerve Root Compression

Physical Signs : C7 nerve root affected most often (45-60°/£>), with weakness in triceps and finger flexors and extensors. C6 nerve root involvement also common, with weakness in biceps brachioradialis wrist extensors.

Mechanical Neck Pain

Physical Signs : Local muscle tenderness, pain on movement. No neurologic deficits. Possible trigger points in fibromyalgia. Torticollis if prolonged abnormal neck posture and muscle spasm.

Sciatica (Radicular Low Back Pain

Physical Signs : pisc herniation most likely if calf wasting weak ankle dorsiflexion absent ankle jerk positive crossed straight-leg raise (pain in affected leg when healthy leg tested)' negative straight-leg raise makes diagnosis highly unlikely. Xpsilateral straight-leg raise sensitive about 65-98% but not specific about 10-60%.

Cervical Myelopathv-from Cervical Cord Compression

Physical Signs: Hypeueflexia1 clonus at the wrist, knee, or ankle1 extensor plantar reflexes (positive Babinski signs); and gait disturbances May also see Lhermitte sign: neck flexion with resulting sensation of electrical shock radiating down the spine. Confirmation of cervical myelopathy warrants neck immobilization and neurosurgical evaluation.

Mechanical Neck Pain-Whiplash*

Physical Signs: Localized paracervical tenderness decreased neck range of motion perceived weakness of the upper extremities. Causes of cervical cord compression such as fracture, herniation, head injury, or altered consciousness are excluded.

Chronic Back Stiffness

Possible Causes : Ankylosing spondylitis, an inflammatory polyarthritis, most common in men younger than 40 yrs. Diffuse idiopathic Hyperostosis (DISH) affects men more than women usually age >50 yrs.

Lumbar spinal Stenosis

Possible Causes : Arises from, hypertrophic degenerative disease of one or more vertebral facets and thickening of the ligamentum flavum, causing narrowing of the spinal canal centrally or in lateral recesses. More common after age 60 yrs.

Mechanical Neck Pain

Possible Causes : Mechanism poorly understood, possibly sustained muscle contraction. Associated with poor posture, stress, poor sleep, poor head position during activities such as computer use watching television, and driving.

Mechanical Neck Pain - Whiplash

Possible Causes : Musculoligamentous sprain or strain from forced hyperflexion-hyperextension injury to the neck, as in rear-end collisions.

Pain Referred from the Abdomen or Pelvis

Possible Causes : Peptic ulcer pancreatitis pancreatic cancer chronic prostatitis, endometriosis, dissecting aortic aneurysm retroperitoneal tumor and other causes.

Sciatica (Radicular Low Back Pain

Possible Causes : Sciatic pain is sensitive,-95%, and specific, , for disc herniation. Usually from herniated intervertebral disc with compression or traction of nerve root(s) in people ages 50 yrs or older. L5 and $1 roots are involved in-95% of disc herniations- root or spinal cord compression from neoplastic conditions in fewer than 1% of cases. Tumor or midline disc herniation may cause bowel or bladder dysfunction leg weakness from cauda equina syndrome (S2-S4).

Cervical Myelopathy-from Cervical Cord Compression

Possible Causes : Usually from cervical spondylosis defined as cervical degenerative disc disease from spurs, protrusion of ligamentum flavum, and/or disc herniation (-80%)' also from cervical stenosis from osteophytes, ossification of iigamentum. flavum, and RA. Urge central or paracentral disc herniation may also compress cord.

Cervical Radiculopathy-from Nerve Root Compression

Possible Causes : dysfunction of cervical spinal nerve nerve roots, or both from foraminal encroachment of the spinal nerve (-75%), herniated cervical disc (-25%). Rarely from tumor syrinx, or multiple sclerosis. Mechanisms may involve hypoxia of the nerve root and dorsal ganglion and release of inflammatory mediators.

Mechanical Low Back Pain:

Possible Causes: Often anses from muscle and ligament injuries (-70%) or age-related intervertebral disc or facet disease (4%)- Causes also include herniated disc (-4%), spinal stenosis (-3%) compression fractures (-4%) and spondylolisthesis 2%

Sciatica (Radicular Low Back Pain)

Shooting pain below the knee commonly into the lateral leg (L5) or posterior calf (SI); typically accompanies low back pain, often with associated paresthesias and weakness. Bending, sneezing coughing, straining during bowel movements can worsen the pain.

Anterior Dislocation of the Humerus

Shoulder instability from anterior subluxation or dislocation of the humerus usually results from a fall or forceful throwing motion, then can become common unless treated or the precipitating motion is avoided. The shoulder seems to "slip out of the joint" when the arm is abducted and externally rotated, causing a positive apprehension sign for anterior instability when the examiner places the arm in this position. Any shoulder movement may cause pain and patients hold the arm in a neutral position. The rounded lateral aspect of the shoulder appears flattened. Dislocations may also be inferior, posterior (relatively rare), and multidirectional.

Flat Feet

Signs of flat feet may be apparent only when the patient stands, or they 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. Flat feet may be a normal variant or arise from posterior tibial tendon dysfunction, seen in obesity, diabetes, and prior foot injury. Inspect the shoes for excess wear on the inner sides of the soles and heels.

Rheumatoid Nodules

Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna in patients with RA or acute rheumatic fever. They are firm and nontender. They are not attached to the overlying skin but may be attached to the underlying periosteum. They can develop in the area of the olecranon bursa but often occur more distally.

Olecranon Bursitis

Swelling and inflammation of the olecranon bursa may result from trauma gout, or rheumatoid arthritis (RA). The swelling is superficial to the olecranon process and may reach 6 cm. in diameter. Consider aspiration for both diagnosis and symptomatic relief.

Acute Rheumatoid Arthritis

Tender, painful, stiff joints in RA usually with symmetric involvement on both sides of the body. The distal interphalangeal (DIP), metacarpophalangeal (MCP) and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease.

Dupuytren Contracture

The first sign of a Dupuytren contracture is a thickened band overlying the flexor tendon of the fourth finger and possibly the little finger near the distal palmar crease. Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops between the palm and finger. Finger extension is limited but flexion is usually normal. Flexion contracture of the fingers may gradually develop.

Trigger Finger

Trigger finger is caused by a painless nodule in a flexor tendon in the palm near the metacarpal head. The nodule is too big to enter easily into the tendon sheath during extension of the fingers from a flexed position With extra effort or assistance the finger extends and flexes with a palpable and audible snap as the nodule pops into the tendon sheath. Watch listen, and palpate the nodule as the patient flexes and extends the fingers.

Ingrown Toenail

The sharp edge of a toenail may dig into and injure the lateral nail fold resulting in inflammation and infection. A tender, reddened overhanging nail fold, sometimes with granulation tissue and purulent discharge results. The great toe is most often affected.

Corn

A com is a painful conical thickening of skin that results from recurrent pressure ob normally thin skin. The apex of the cone points inward and causes pain. Corns characteristically occur over bony prominences such as the fifth toe. When located in moist areas such as pressure points between the fourth and fifth toes, they are called soft corns.

Mechanical Neck Pain

Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm and stiffness and tightness in the upper back and shoulder lasting up to 6 wks. No associated radiation. paresthesias, or weakness. Headache may be present.

Mechanical Low Back Pain:

Aching pain in the lumbosacral area- may radiate into lower leg especially in 15 (lateral leg) or SI (posterior leg) dermatomes. Signifies anatomic or functional abnormality in absence of neoplastic infectious, or inflammatory disease. Usually acute (<3 mo) idiopathic benign and selflimiting; represents 97% of symptomatic low back pain. Commonly work related and occurring in patients 30-50 yrs. Risk factors include heavy lifting poor conditioning obesity.

Acromioclavicular Arthritis

Acromioclavicular arthritis is relatively common usually arising from prior direct injury to the shoulder girdle with resulting degenerative changes. Tenderness is localised over the acromioclavicular joint. Patients report pain with movements of the scapula and arm abduction.

Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis refers to 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, especially in external rotation with localized tenderness. The condition is usually unilateral and occurs in people ages 40-60 yrs. There is often an antecedent disorder of the shoulder or another condition (such as myocardial infarction) that has decreased shoulder movements. The disorder may take 6 mo to 2 yrs to resolve. Stretching exercises may help.

Rotator Cuff Tears

The rotator cuff muscles and tendons compress the humeral head into the concave glenoid fossa and strengthen arm movement-the subscapularis in internal rotation the supraspinatus in elevation, and the infraspinatus and teres minor in external rotation. Injury from a fall trauma, or repeated impingement against the acromion and the coracoacromial ligament may cause a partial- or full-thickness tear of the rotator cuff the most common clinical problem of the shoulder, especially in older patients. Patients complain of chronic shoulder pain night pain, or catching and grating when raising the arm overhead. Weakness or tears of the tendons usually start in the supraspinatus tendon and progress posteriorly and anteriorly Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. In a complete tear active abduction and forward flexion at the glenohumeral joint are severely impaired producing a characteristic shrug of the shoulder and a positive "drop arm" test

Thenar Atrophy

Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome (see p. 664). Hypothenar atrophy suggests an ulnar nerve disorder.

Nocturnal Back Pain, Unrelieved by rest

physical Signs : Loss of the normal lumbar lordosis, muscle spasm, limited anterior and lateral flexion, lateral immobility of the spine, especially in thoracic area improves with exercise.

Mechanical Low Back Pain:

physical Signs: paraspinal muscle or facet tenderness, pain with back movement loss of normal lumbar lordosis- motor, sensory, and reflex findings are normal. In osteoporosis check for thoracic kyphosis, percussion tenderness over a spinous process, or fractures in the thoracic spine or hip

Lumbar spinal Stenosis

pleurogenic claudication with gluteal and/or lower extremity pain and/or fatigue that may occur with or without back pain. Pain is provoked by lumbar extension (as in walking uphill) due to reduced space in the lumbar spine from degenerative changes in the spinal canal. Positive LR is >6.0 if pain is absent when seated improved with bending forward or present in both buttocks and legs. Positive LR is <4.0 if gait is wide-based and Romberg test is abnormal.

Nocturnal Back Pain, Unrelieved by rest

possible Causes : Consider metastatic malignancy to the spine from cancer of the prostate breast lung thyroid and kidney, and multiple myeloma.