Patient Assessment (tiburzi) Neuro

Range of Motion and Maneuvers- hip

*Normal values for hip flexion, abduction, and adduction are 120°, 45°, and 20° respectively. -Flexion: Iliopsoas, "Bend your knee to your chest and pull it against your abdomen." -Extension (actually hyperextension): Gluteus maximus. "Lie face down, then bend your knee and lift it up." OR "Lying flat, move your lower leg away from the midline and down over the side of the table." -Abduction : Gluteus medius and minimus. "Lying flat, move your lower leg away from the midline." -Adduction: Adductor brevis, adductor longus, adductor magnus, pectineus, gracilis. "Lying flat, bend your knee and move your lower leg toward the midline." -External Rotation: Internal and external obturators, quadratus femoris, superior and inferior gemelli. "Lying flat, bend your knee and turn your lower leg and foot across the midline." -Internal Rotation: Iliopsoas. Lying flat, bend your knee and turn your lower leg and foot away from the midline."

Rotator cuff tests

--Rotator cuff disorders are the most common cause of shoulder pain in primary care. Compression of the rotator cuff muscles and tendons between the head of the humerus and the acromion causes "impingement signs" or pain during shoulder movement. ****An age of ≥60 years and a positive drop-arm test are the findings most likely to identify a degenerative rotator cuff tear -Pain provocation test: painful arc test (subacromial bursa and rotator cuff ), Strength tests: internal rotation lag test (subscapularis), external rotation lag test (supraspinatus and infraspinatus), and drop arm test (supraspinatus), Composite test: external rotation resistance test (infraspinatus).

Adduction (or Varus) Stress Test

-Lateral Collateral Ligament (LCL) test -With the thigh and knee in the same posi- tion, change your position so that you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress). *****Pain or a gap in the lateral joint line points is a positive test for LCL injury (less common than MCL injuries)

Lachman Test

-Place the knee in 15° of flexion and external rotation. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. With the thumb of the tibial hand on the joint line, simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion. ****Significant forward excursion is a pos- itive test for an ACL tear

Anterior Drawer Sign

-Test for Anterior Cruciate Ligament (ACL) -With the patient supine, hips flexed and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Com- pare the degree of forward move- ment with that of the opposite knee. *****A few degrees of forward movement are normal if equally present on the opposite side. *****A forward jerk showing the contours of the upper tibia is a positive test, or anterior drawer sign *****ACL injuries result from knee hyperex- tension, direct blows to the knee, and twisting or landing on an extended hip or knee.

Synovial Joints.

-The bones of these joints do not touch each other, and the joint articulations are freely movable within the limits of the surrounding ligaments (Fig. 16-3). The bones are covered by articular cartilage and separated by a synovial cavity that cushions joint movement. A synovial membrane lines the synovial cavity and secretes a small amount of viscous lubricating fluid, the synovial fluid. The membrane is attached at the margins of the articular cartilage and pouched or folded to accommodate joint movement. Surrounding the joint is a fibrous joint capsule, which is strengthened by ligaments extending from bone to bone.

Fibrous Joints

In these joints, such as the sutures of the skull, intervening layers of fibrous tissue or cartilage hold the bones together (Fig. 16-5). The bones are almost in direct contact, which allows no appreciable movement.

Tips for Assessing Joint Pain

● Ask the patient to "point to the pain." This may save considerable time because many patients have trouble pinpointing pain location in words. ● Clarify and record when the pain started and the mechanism of injury, particularly if there is a history of trauma. ● Determine whether the pain is articular or extra-articular, acute or chronic, inflammatory or noninflammatory, and localized (monoarticular) or diffuse (polyarticular).

Common or Concerning Symptoms

● Joint pain: articular or extra-articular, acute or chronic, inflammatory or noninflammatory, localized or diffuse ● Joint pain: associated constitutional symptoms and systemic manifestations from other organ systems ● Neck pain ● Low back pain

Cartilaginous Joints

These joints, such as the intervertebral joints and the symphysis pubis, are slightly movable (Fig. 16-4). Fibrocartilaginous discs separate the bony surfaces. At the center of each disc is the nucleus pulposus, somewhat gelatinous fibrocartilaginous material that serves as a cushion or shock absorber between bony surfaces

Maneuvers for Examining the Shoulder

-Acromioclavicular Joint: Overall Shoulder Rotation. Crossover or crossed body adduction test. Adduct the patient's arm across the chest. ***Pain with adduction is a positive test -Overall shoulder test: Apley scratch test. Ask the patient to touch the opposite scapula lifting arm back (Tests abduction and external rotation.) and then going around the back (Tests adduction and internal rotation.). ***Pain during these maneuvers suggests a rotator cuff disorder or adhesive capsulitis. -Rotator Cuff (Pain Provocation Tests) Fully adduct the patient's arm from 0° to 180°. ****Shoulder pain from 60° to 120° isa positive test for a subacromial impingement/rotator cuff tendinitis disorder -Neer impingement sign. Press on the scapula to prevent scapular motion with one hand, and raise the patient's arm with the other. This compresses the greater tuberosity of the humerus against the acromion. ****Pain during this maneuver is a positive test for a subacromial impingement/ rotator cuff tendinitis disorder -Hawkins impingement sign. Flex the patient's shoulder and elbow to 90° with the palm facing down. Then, with one hand on the fore- arm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament. ****Pain during this maneuver is a positive test for supraspinatus impingement/ rotator cuff tendinitis, with a positive -Internal rotation lag test. Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°. Then you lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position. *****Inability of the patient to hold the hand in this position is positive test for a subscapularis disorder -Drop-arm test. Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle. *****Weakness during this maneuver is a positive test for a supraspinatus rota- tor cuff tear or bicipital tendinitis, -Composite tests: *External rotation resistance test. Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pres- sure proximal to the patient's wrist as the patient presses the wrist outward in exter- nal rotation. ******Pain or weakness during this maneuver is a positive test for an infraspinatus disorder. Limited external rotation points to glenohumeral disease or adhesive capsulitis. *Empty can test. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms ******Inability of the patient to hold the arm fully abducted at shoulder level or control lowering the arm is a positive test for a suprasinatus rotator cuff tear

Discerning acute v chronic joint pain

-Acute joint pain typically lasts up to 6 weeks; chronic pain lasts >12 weeks. -Assess the onset, duration, quality, and severity of the joint symptoms. Onset is especially important. Did the pain or discomfort develop rapidly over the course of a few hours or insidiously over weeks or even months? Has the pain progressed slowly or fluctuated, with periods of improvement and worsening? ******Severe pain of rapid onset in a red swollen joint suggests acute septic arthritis or crystalline arthritis. In children, consider osteomyelitis in a bone contiguous to a joint. -If more rapid in onset, how did the pain arise? Was there an acute injury or overuse from repetitive motion of the same part of the body? If the pain comes from trauma, what was the mechanism of injury or the specific series of events that caused the joint pain?

Discerning Localized or Diffuse joint pain

-Ask the patient which joints are painful. Joint pain can be monoarticular, oligoarticular involving two to four joints, or polyarticular. If there is pain in more than one joint, is the pattern of involvement symmetric or asymmetric? *****Monoarticular arthritis can be traumatic, crystalline, or septic. Oligoarticular arthritis occurs in infection from gonorrhea or rheumatic fever, connective tissue disease, and OA. Polyarthritis may be viral or inflammatory from RA, SLE, or psoriasis. *****Involvement is usually symmetric in RA, SLE, and ankylosing spondylitis and asymmetric in psoriatic, reactive (Reiter), and IBD-associated arthritis.

Fingers and Thumbs: Range of Motion and Maneuvers

-Assess flexion, extension, abduction, and adduc- tion of the fingers. -Flexion and extension. For flexion, to test the lumbricals and finger flexor muscles, ask the patient to "Make a tight fist with each hand, thumb across the knuckles." For ex- tension, to test the finger extensor muscles, ask the patient to "Extend and spread the fingers." At the MCPs, the fingers may extend beyond the neutral position. Test the flexion and extension of the PIP and DIP joints (lumbrical muscles). The fingers should open and close easily. -Abduction and adduction. Ask the patient to spread the fingers apart (abduction from dorsal interossei) and back together (adduction from palmar interossei). Check for smooth, coordinated movement *****Inspect for impaired hand movement in arthritis, trigger finger, and Dupuy- tren contracture Thumbs. -At the thumb, assess flexion, extension, abduction, adduction, and opposition. Each of these movements is powered by a related muscle of the thumb. -move the thumb across the palm and touch the base of the fifth finger to test flexion, and then to move the thumb back across the palm and away from the fingers to test extension. -ask the patient to place the fingers and thumb in the neutral position with the palm up, then have the patient move the thumb anteriorly away from the palm to assess abduction and back down for adduction. To test opposition, or movements of the thumb across the palm, ask the patient to touch the thumb to each of the other fingertips.

Discerning whether joint pain is inter or extra articular

-Begin by asking "Do you have any pains in your joints?" Joint pain may be articular or extra-articular. Ask the patient to point to the pain. -If pain is localized to only one joint, it is monoarticular. -Pain originating in the small joints of the hands and feet is more sharply localized than pain in larger joints. Pain from the hip joint is especially deceptive. True pain from the hip joint is typically described in the groin. Sacral/sacroiliac pain is often in the buttock, and trochanteric pain from bursitis occurs on the lateral thigh. ****Pain in a single joint suggests injury, monoarticular arthritis, or extra- articular causes like tendinitis or bur- sitis. Lateral hip pain with focal ten- derness over the greater trochanter is typical of trochanteric bursitis. -Joint pain may be polyarticular, involving several joints, typically four or more. If 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 sides of the body? *****In rheumatic fever or gonococcal arthritis, there is a migratory pattern of spread; in RA, the pattern is addi- tive and progressive with symmetric involvement. Inflammatory arthritides are more common in women. -Joint pain may also be extra-articular, involving bones, muscles, and tissues around the joint such as the tendons, bursae, or even overlying skin. Gener- alized "aches and pains" are called myalgias if in muscles, and arthralgias if there is pain but no evidence of arthritis. ****Extra-articular pain occurs in inflam- mation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis) as well as in sprains from stretching or tearing of ligaments -Note that the symptoms of decreased joint movement and stiffness can help you decide if the pain is articular. To assess decreased or limited movement, ask about changes in activity due to problems with the involved joint, for example, in the ability to walk, stand, lean over, sit or sit up, etc. Musculoskeletal stiffness refers to a perceived tightness or resistance to movement, in contrast to normal movement that is limber. ****In articular joint pain there is decreased active and passive range or motion and morning stiffness or "gelling"; in nonarticular joint pain, there is periarticular tenderness and only passive range of motion remains intact.

Palpation- hip

-Bony Landmarks. *Anterior Landmarks ● Identify the iliac crest at the upper margin of the pelvis at the level of L4. ● Follow the downward anterior curve and locate the iliac tubercle, marking the widest point of the crest, and continue tracking downward to the anterior- superior iliac spine. ● Place your thumbs on the anterior-superior spines and move your fingers downward and laterally from the iliac tubercles to the greater trochanter of the femur. ● Then move your thumbs medially and obliquely to the pubic tubercle, which lies at the same level as the greater trochanter. *Posterior Landmarks ● Palpate the posterior-superior iliac spine directly underneath the visible dim- ples just above the buttocks. ● Placing your left thumb and index finger over the posterior superior iliac spine, next locate the greater trochanter laterally with your fingers at the level of the gluteal fold, and place your thumb medially on the ischial tuberosity. The sacroiliac joint is not always palpable but may be tender. Note that an imagi- nary line along the posterior-superior iliac spines crosses the joint at S2. *****Sacroiliac joint tenderness suggests sacroiliitis. -Inguinal Structures. With the pa- tient supine, ask the patient to place the heel of the leg being examined on the opposite knee. Then palpate along the inguinal ligament, which extends from the anterior-superior iliac spine to the pubic tubercle ******Bulges along the ligament suggest an inguinal hernia or, at times, an aneurysm. Enlarged lymph nodes point to infection in the pelvis or lower extremity. -The mnemonic NAVEL may help you remember the lateral- to-medial sequence of Nerve-Artery-Vein-Empty space-Lymph node. ******Causes of groin tenderness are synovi- tis of the hip joint, arthritis; bursitis; or possible psoas abscess. *******Focal tenderness over the trochanter confirms trochanteric bursitis. Tenderness over the posterolateral surface of the greater trochanter occurs in local- ized tendinitis, muscle spasm from referred hip pain, and iliotibial band tendinitis. -Anterior or inguinal pain, typically deep within the hip joint and radiating to the knee, points to intra-articular pathology; pain radiating to the buttocks or pos- terior trochanteric region points to extra-articular causes. *****Intra-articular causes include OA, osteonecrosis of the femoral head, acetabular labral tears, and femoral neck stress fracture. Extra-articular causes include trochanteric bursitis, muscle strain, sacroiliac disorders, and lumbar radiculopathy -Bursae. *If the hip is painful, palpate the (psoas) bursa, below the inguinal ligament but on a deeper plane. With the patient resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa lying over the greater trochanter. Normally, the ischiogluteal bursa, over the ischial tuberosity, is not palpable unless inflamed ******Look for tenderness in ischiogluteal bursitis or "weaver's bottom"; because of the adjacent sciatic nerve, this may mimic sciatica.

Bursae.

-Bursae are roughly disc-shaped synovial sacs that ease joint action and allow adjacent muscles or muscles and tendons to glide over each other during movement. They lie between the skin and the convex surface of a bone or joint, as in the prepatellar bursa of the knee (p. 684) or in areas where tendons or muscles rub against bone, ligaments, or other tendons or muscles, as in the subacromial bursa of the shoulder

The Ankle and Foot- overview/bones

-Despite thick padding along the toes, sole, and heel and stabilizing ligaments at the ankles, the ankle and foot are frequent sites of sprain and bony injury. -Bony Structures and Joints: *ankle is a hinge joint formed by the tibia, the fibula, and the talus. The tibia and fibula act as a mortise, stabilizing the joint while bracing the talus like an inverted cup. *The principal joints of the ankle are the tibiotalar joint, between the tibia and the talus, and the subtalar (talocalcaneal) joint *Note the principal landmarks of the ankle: the medial malleolus, the bony prominence at the distal end of the tibia, and the lateral malleolus, at the distal end of the fibula. Lodged under the talus and jutting posteriorly is the calcaneus, or heel bone. *The heads of the metatarsals are palpable in the ball of the foot. In the forefoot, identify the metatarsophalangeal joints, proximal to the webs of the toes, and the PIP and DIP joints of the toes.

Discerning Inflammatory or Noninflammatory joint pain

-Different mechanisms appear to be involved—interleukins and tumor necrosis factor in inflammatory joint pain, and prostaglandins, chemokines, and growth factors in noninflammatory pain *****Inflammatory disorders have many causes: infectious (Neisseria gonor- rhoeae or Mycobacterium tuberculosis), crystal-induced (gout, pseudogout), immune-related (RA, systemic lupus ery- thematosus [SLE]), reactive (rheumatic fever, reactive arthritis), or idiopathic. ******In noninflammatory disorders, consider trauma (rotator cuff tear), repetitive use (bursitis, tendinitis), degenerative changes (OA), or fibromyalgia. -Ask about the four cardinal features of inflammation—swelling, warmth, and redness, in addition to pain. *****Inflammation with fever and chills is seen in septic arthritis; also consider crystalline arthritis. -Elicit any pattern of stiffness. Is it worse in the morning but gradually better with activity? Or is there an intermittent "gel phenomenon," namely brief periods of daytime stiffness following inactivity that usually last from 30 to 60 minutes then get worse again with movement? *****Morning stiffness that gradually improves with activity is more common in inflammatory disorders like RA and PMR9-11; intermittent stiffness and gelling are seen in OA. *In inflammatory conditions, initial laboratory tests such as the erythrocyte sedimentation rate, C-reactive protein, platelet count, and hematocrit are helpful.

Assessing Fracture Risk.

-FRAX calculator generates a 10-year osteoporotic fracture risk based on age; gender; weight; height; parental fracture history; use of glucocorticoids; presence of RA or conditions associated with secondary osteoporosis; tobacco and heavy alcohol use; and, when available, femoral neck BMD. -The FRAX calculator also provides a 10-year hip fracture risk ****A previous low-impact fracture from standing height or lower is the great- est risk factor for subsequent fracture.

Range of Motion and Maneuvers- Spine

-Flexion: *Psoas major, psoas minor, quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as the internal and external obliques and rectus abdominis *"Bend forward and try to touch your toes." Note the smoothness and symmetry of move- ment, the range of motion, and the curve in the lumbar area. As flexion proceeds, the lumbar concavity should flatten out. ******Deformity of the thorax on forward bending, especially when the height of the scapulae is unequal, suggests scoliosis. *******Persistence of lumbar lordosis sug- gests muscle spasm or ankylosing spondylitis -Extension *Deep intrinsic muscles of the back, such as the erector spinae and transversospinalis groups *"Bend back as far as possible." Support the patient by placing your hand on the posterior superior iliac spine, with your fingers pointing toward the midline. *****Decreased spinal mobility is common in OA and ankylosing spondylitis. -Rotation *Abdominal muscles, intrinsic muscles of the back *"Rotate from side to side." Stabilize the patient's pelvis by placing one hand on the patient's hip and the other on the opposite shoulder. *Then rotate the trunk by pulling the shoulder anteriorly and then the hip posteriorly. Repeat these maneuvers for the opposite side. -Lateral Bending *Abdominal muscles, intrinsic muscles of the back *"Bend to the side from the waist." Stabilize the patient's pelvis by placing your hand on the patient's hip. Repeat for the opposite side *If these maneuvers provoke pain or tenderness, particularly with radiation into the leg, proceed to careful neurologic testing of the lower extremities. *Non-organic physical findings (Waddell signs) include superficial or nonana- tomic tenderness, pain on axial loading or simulated rotation, nonreproducibil- ity of pain when the patient is distracted, regional weakness or sensory change, and overreaction to stimuli that should not cause back pain *******Consider lumbosacral cord or nerve root compression; arthritis, mass lesion, or infection in the hip, rectum, or pelvis may also cause symptoms.

Maneuvers- Hip

-Flexion: With the patient supine, place your hand under the patient's lumbar spine. Ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen. Note that the hip can flex further when the knee is flexed because the hamstrings are relaxed. When the back touches your hand, indicating normal flattening of the lumbar lordosis, further flexion must arise from the hip joint itself. *****In flexion deformity of the hip, as the opposite hip is flexed (with the thigh against the chest), the affected hip does not allow full hip extension and the affected thigh appears flexed Inspect the degree of flexion at the hip and knee. Normally, the anterior portion of the thigh can almost touch the chest wall. Note whether the opposite thigh remains fully extended, rest- ing on the table. ******Flexion deformity may be masked by an increase, rather than flattening, in lumbar lordosis and an anterior pelvic tilt. -Extension: With the patient lying facedown, extend the thigh toward you in a posterior direction. Alternatively, carefully position the supine patient near the edge of the table and extend the leg posteriorly. -Abduction. Stabilize the pelvis by pressing down on the opposite anterior-superior iliac spine with one hand. With the other hand, grasp the ankle and abduct the extended leg until you feel the iliac spine move. This movement marks the limit of hip abduction. *****Restricted abduction and internal and external rotation are common in hip OA. -Adduction: With the patient supine, stabilize the pelvis, hold one ankle, and move the leg medially across the body and over the opposite extremity -External and internal rotation: Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg—medially for external rotation at the hip, and laterally for internal rotation. Although confusing at first, it is the motion of the head of the femur in the acetabulum that identifies these movements. *****Pain with maximal flexion and adduc- tion and internal rotation or with abduction and external rotation with full extension signals acetabular labral tear.

Range of Motion and Maneuvers

-Flexion: Hamstring group: biceps femoris, semitendinosus, and semimembranosus. "Bend or flex your knee." OR "Squat down to the floor." -Extension: Quadriceps: rectus femoris, vastus medialis, lateralis, and intermedius. "Straighten your leg." OR "After you squat down to the floor, stand up." -Internal Rotation: Sartorius, gracilis, semitendi- nosus, semimembranosus. "While sitting, swing your lower leg toward the midline." -External Rotation: Biceps femoris. "While sitting, swing your lower leg away from the midline." ***Crepitus with flexion and extension signals patellofemoral OA, a probable precursor of knee OA.

carpal tunnel syndrome

-For complaints of nocturnal hand or arm numbness, dropping objects, inability to twist lids off jars, aching at the wrist or even the forearm, and numbness of the first three digits, test for carpal tunnel syndrome, the most common entrapment neuropathy, involving compression of the median nerve. ****Forceful repetitive handwork with wrist flexion such as keyboarding or mail sorting, vibration, cold environments, wrist anatomy, pregnancy, RA, diabetes, and hypothyroidism are risk factors for carpal tunnel syndrome *****Decreased sensation in the median nerve territory is a common sign of carpal tunnel syndrome (sensitivity to pinprick and two-point discrimination

Muscle Groups of hips

-Four powerful muscle groups move the hip. *The flexor group lies anteriorly and flexes the thigh. The primary hip flexor is the iliopsoas, extend- ing from above the iliac crest to the lesser trochanter. The extensor group lies posteriorly and extends the thigh. The gluteus maximus is the primary extensor of the hip. It forms a band crossing from its origin along the medial pelvis to its insertion below the trochanter. *The adductor group is medial and swings the thigh toward the body. The muscles in this group arise from the rami of the pubis and ischium and insert on the posteromedial aspect of the femur. The abductor group is lateral, extending from the iliac crest to the greater trochanter, and moves the thigh away from the body. This group includes the glu- teus medius and minimus. These muscles help stabilize the pelvis during the stance phase of gait. -Additional Structures: A strong, dense articular capsule, extending from the acetabulum to the femoral neck, encases and strengthens the hip joint. The capsule is reinforced by three overlying ligaments and lined with synovial membrane. There are three principal bursae at the hip. Anterior to the joint is the psoas (also termed iliopectineal or iliopsoas) bursa, overlying the articular capsule and the psoas muscle. Find the bony prominence lateral to the hip joint—the greater trochanter of the femur. The large multilocular trochanteric bursa lies on its posterior surface. The ischial (or ischiogluteal) bursa, not always present, lies under the ischial tuberosity, and accommodates the weight of the sitting position. Note its proximity to the sciatic nerve

nutrition, Weight, and Physical Activity.

-Good nutrition supplies calcium for bone mineralization and bone density. A healthy weight reduces excess mechanical stress on weight-bearing joints like the hips and knees -Physical Activity Guidelines for Americans: ● At least 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination ● Moderate- or high-intensity muscle-strengthening activity that involves all major muscle groups on 2 or more days a week

Osteoporosis: Risk Factors, Screening, and Assessing Fracture Risk.

-Half of all postmenopausal women sustain an osteoporosis-related fracture during their lifetime; 25% develop vertebral deformities; and 15% suffer hip fractures that increase risk of chronic pain, disability, loss of independence, and increased mortality. -Men are also at risk: the lifetime risk for an osteoporotic fracture in men over age 50 years is 1 in 4, and men are more likely than women to die in the year following a hip fracture. -Risk Factors for Osteoporosis: ● Postmenopausal status in women ● Age ≥50 years ● Prior fragility fracture ● Low body mass index ● Low dietary calcium ● Vitamin D deficiency ● Tobacco and excessive alcohol use ● Immobilization ● Inadequate physical activity ● Osteoporosis in a first-degree relative, particularly with history of fragility fracture ● Clinical conditions such as thyrotoxicosis, celiac sprue, IBD, cirrhosis, chronic renal disease, organ transplantation, diabetes, HIV, hypogonadism, multiple myeloma, anorexia nervosa, and rheumatologic and autoimmune disorders ● Medications such as oral and high-dose inhaled corticosteroids, anticoagulants (long-term use), aromatase inhibitors for breast cancer, methotrexate, selected antiseizure medications, immunosuppressive agents, proton-pump inhibitors (long-term use), and antigonadal therapy for prostate cancer *osteoporosis screening for women age ≥65 years and for younger women whose 10-year fracture risk equals or exceeds that of an average-risk 65-year-old white woman. *Bone strength depends on bone quality, bone density, and overall bone size. Because there is no direct measure of bone strength, bone mineral density (BMD)—which provides roughly 70% of bone strength—is used as a reasonable surrogate. Dual energy x-ray absorptiometry (DEXA) scan- ning of the lumbar spine and femoral neck is the optimal standard for measuring bone density, diagnosing osteoporosis, and guiding treatment decisions. DEXA measurement of bone density at the femoral neck is considered the best predictor of hip fracture. *****Bone mass peaks by age 30 years. Bone loss from age-related declines in estrogen and testosterone is initially rapid, then slows and becomes con- tinuous. -Osteoporosis: T score < −2.5 (>2.5 SDs below the young adult mean) -Osteopenia: T score between −1.0 and −2.5 (1.0 to 2.5 SDs below the young adult mean)

Age related to joint pain

-If age <60 years, consider repetitive strain or overuse syndromes like tendinitis or bursitis, crystalline arthritis (gout; crystalline pyrophosphate deposition disease [CPPD]) (males), rheumatoid arthritis (RA), psoriatic arthritis and reactive (Reiter) arthritis (in inflammatory bowel disease [IBD]), and infectious arthritis from gonorrhea, Lyme disease, or viral or bacterial infections. If age >60 years, look for OA, gout and pseudogout, polymyalgiarheumatica (PMR), osteoporotic fracture, and septic bacterial arthritis.

Negative Infrapatellar Space and Suprapatellar Pouch.

-Inspect the concavities that are usually evident adjacent and superior to each side of the patella, known as the "negative infrapatellar space". Occupying these areas is the synovial cavity of the knee, one of the largest joint cavities in the body. This cav- ity includes an extension 6 cm above the upper border of the patella, lying upward and deep to the quadriceps muscle, called the suprapatellar pouch. The joint cavity covers the anterior, medial, and lateral surfaces of the knee, as well as the condyles of the femur and tibia posteriorly. Although the synovium is not normally palpable, these areas may become swollen and tender when the joint is inflamed or injured

Techniques of Examination: Wrist/hand

-Inspection. *Inspect the position of the hands in motion for smooth natural movement. When the fingers are relaxed they should be slightly flexed; the fingernail edges should be in parallel. *****Guarded movement suggests injury. Flexor tendon damage causes abnormal finger alignment. *Inspect the palmar and dorsal surfaces of the wrist and hand carefully for swell- ing over the joints or signs of trauma. ******Diffuse swelling is common in arthritis or infection; local swelling suggests a gan- glion. Laceration, puncture, injection marks, burn, or erythema result from trauma. *Note any deformities of the wrist, hand, or finger bones, as well as any angulation. *****Heberden nodes (DIP joints) and Bouchard nodes (PIP joints) are common findings in OA. In RA, inspect for symmetric deformity in the PIP, MCP, and wrist joints; later, there is MCP subluxation and ulnar deviation. *Observe the contours of the palm, namely the thenar and hypothenar eminences. *****Thenar atrophy occurs in median nerve compression from carpal tunnel syndrome; in ulnar nerve com- pression, there is hypothenar atrophy. *Note any thickening of the flexor tendons or flexion contractures in the fingers *****Dupuytren flexion contractures in the third, ring, and fifth fingers, arise from thickening of the palmar fascia -Palpation. At the wrist, palpate the distal radius and ulna on the lateral and medial surfaces. Palpate the groove of each wrist joint with your thumbs on the dorsum of the wrist, your fingers beneath it. Note any swelling, bogginess, or tenderness. *****Tenderness over the distal radius after a fall is suspicious for a Colles fracture. Bony step-offs also suggest fracture. *****In RA, there is persisting bilateral swelling and/or tenderness. *Palpate the radial styloid bone and the anatomic snuffbox, a hollowed depression just distal to the radial styloid process formed by the abductor and extensor muscles of the thumb ******Tenderness over the extensor and abductor tendons of the thumb at the radial styloid occurs in de Quervain tenosynovitis and gonococcal tenosy- novitis. *****"Snuffbox" tenderness with the wrist in ulnar deviation and pain at the scaph- oid tubercle are suspicious for occult scaphoid fracture, a common injury. Poor blood supply increases risk of scaphoid bone avascular necrosis. *Palpate the eight carpal bones lying distal to the wrist joint, and then each of the five metacarpals and the proximal, middle, and distal phalanges *****The MCPs are often boggy or tender in RA, but are rarely involved in OA. Pain with compression also occurs in posttraumatic arthritis *Compress the MCP joints by squeez-ing the hand from each side betweenthe thumb and fingers. Note any swelling, bogginess, or tenderness. *Now examine the fingers and thumb. Palpate the medial and lateral aspects of each PIP joint between your thumb and index finger, again checking for swelling, bogginess, bony enlargement, or tenderness. *****There are PIP changes in RA; Bouchard nodes in OA. Pain at the base of the thumb occurs in carpometacarpal arthritis. *Using the same techniques, examine the DIP joints *****Hard dorsolateral nodules on the DIP joints, or Heberden nodes (Fig. 16-35), are common in OA; the DIP joints are also involved in psoriatic arthritis. *In any area of swelling or inflammation, palpate along the tendons inserting on the thumb and fingers. *****Tenderness and swelling occur in tenosynovitis, or inflammation of the tendon sheaths. De Quervain tenosy- novitis involves the extensor and abductor tendons of the thumb as they cross the radial styloid.

Techniques of Examination- hips

-Inspection. *Inspection of the hip begins with careful observation of the patient's gait when entering the room. Observe the two phases of gait: ---Stance—when the foot is on the ground and bears weight (60% of the walking cycle) *****Most hip problems appear during the weight-bearing stance phase. ---Swing—when the foot moves forward and does not bear weight (40% of the cycle) Inspect the gait for the width of the base, the shift of the pelvis, and flexion of the knee. The width of the base should be 2 to 4 inches from heel to heel. Normal gait has a smooth, continuous rhythm, achieved in part by contraction of the abductors of the weight-bearing limb. Abductor contraction stabilizes the pelvis and helps maintain balance, raising the opposite hip. The knee should be flexed throughout the stance phase, except when the heel strikes the ground to counteract motion at the ankle. *****A wide base suggests cerebellar dis- ease or foot problems. Pain during weight bearing or examiner strike on the heel occurs in femoral neck stress fractures. ******Hip dislocation, arthritis, unequal leg lengths, or abductor weakness can cause the pelvis to drop on the opposite side, producing a waddling gait. Lack of knee flexion, which makes the leg functionally longer, interrupts the smooth pattern of gait, causing cir- cumduction (swinging the leg out to the side). *******Loss of lordosis occurs with paraverte- bral spasm; excess lordosis suggests a flexion deformity of the hip. *******Disparities in leg length occur in abduction or adduction deformities and scoliosis. Leg shortening and external rotation are common in hip fracture

Techniques of Examination- Spine

-Inspection. *Inspect the patient's posture when entering the room, including the position of both the neck and trunk. *****Neck stiffness signals arthritis, muscle strain, or other underlying pathology that should be pursued; headache may be present. *patient should be upright in the natural standing position, with feet together and arms at the sides. The head should be midline in the same plane as the sacrum, and the shoulders and pelvis should be level. ******Lateral deviation and rotation of the head are seen in torticollis, from con- traction of the sternocleidomastoid muscle. Viewing the patient from behind, identify the following: -Spinous processes, usually more prominent at C7 and T1 and more evident on forward flexion -Paravertebral muscles on either side of the midline Iliac crests -Posterior superior iliac spines, usually marked by skin dimples. -A line drawn above the posterior iliac crests crosses the spinous process of L4. -Inspect the patient from the side and from behind. Evaluate the spinal curvatures and the features in the display on the next page. Palpation: -From a sitting or standing position, palpate the spinous processes of each vertebra with your thumb. *****Vertebral tenderness raises concerns for fracture, dislocation, underlying infection, or arthritis. -palpate the facet joints that lie between the cervical vertebrae 1 to 2 cm lateral to the spinous processes of C2 to C7. These joints lie deep to the trapezius muscle and may not be palpable unless the neck muscles are relaxed *******Tenderness occurs in arthritis, espe- cially at the facet joints between C5 and C6. -In the lower lumbar area, palpate carefully for vertebral "step-offs" to see if one spinous process seems unusually prominent (or recessed) in relation to the one above it. Identify any tenderness. ********Step-offs occur in spondylolisthesis, or forward slippage of one vertebra, which may compress the spinal cord. -Palpate over the sacroiliac joint, often identified by the dimple overlying the pos- terior superior iliac spine. ********Tenderness over the sacroiliac joint is common in sacroiliitis and ankylosing spondylitis. -You may wish to percuss the spine for tenderness by thumping, but not too roughly, with the ulnar surface of your fist. ********Pain with percussion occurs in verte- bral osteoporotic fractures, infection, and malignancy. -Inspect and palpate the paravertebral muscles for tenderness and spasm. Muscles in spasm feel firm and knotted and may be visible. ******Spasm occurs in degenerative and inflammatory muscle disorders, over- use, prolonged contraction from abnormal posture, and anxiety. -With the patient's hip flexed and the patient lying on the opposite side, palpate the sciatic nerve, the largest nerve in the body, consist- ing of nerve roots from L4, L5, S1, S2, and S3. The sciatic nerve lies midway between the greater trochanter and the ischial tuberosity as it runs through the sciatic notch. It is difficult to pal- pate in most patients. -Assess all low back pain for possible cauda equina compression, the most serious cause of pain, due to risk of limb paralysis or bladder/bowel dysfunction ********Herniated intervertebral discs, most common at L5-S1 or L4-L5, may cause tenderness of the spinous pro- cesses, intervertebral joints, paraver- tebral muscles, sacrosciatic notch, and sciatic nerve

Techniques of Examination of ankle/foot

-Inspection. Observe all surfaces of the ankles and feet, noting any deformities, nodules, swelling, calluses, or corns. -Palpation. With your thumbs, palpate the anterior aspect of each ankle joint, noting any bogginess, swelling, or tenderness ****Localized tenderness is often present in arthritis, ligamentous injury, or infection Feel along the Achilles tendon for nodules and tenderness. *****Check for rheumatoid nodules and tenderness, commonly found in Achil- les tendinitis, bursitis, or partial tear from trauma. Palpate the heel, especially the posterior and inferior calcaneus, and the plantar fascia for tenderness. Bone spurs are common on the calcaneus. *****Focal heel tenderness at the attachment site of the plantar fascia is typical of plantar fasciitis; risk factors are anatomic (overpronation, flat feet), improper foot-wear, excessive use, and overtraining with prolonged heel-strike exercise. Presence or absence of a heel spur does not change the diagnosis Palpate for tenderness over the medial and lateral ankle ligaments and the medial and lateral malleolus, especially in cases of trauma. In trauma, the distal tip of the tibia and fibula should also be palpated. ****Most ankle sprains involve foot inversion and injury to the weaker lateral ligaments (anterior talofibular and calcaneofibular), with overlying ten- derness, swelling, and ecchymosis. *****After trauma, pain in the malleolar zone plus either bone tenderness over the posterior aspects of either malleolus (or over the navicular or base of the fifth metatarsal) or an inability to bear weight for four steps is suspicious for ankle fracture and warrants radiography (known as the Ottawa ankle and foot rules). Palpate the metatarsophalangeal (MTP) joints for tenderness. Compress the forefoot between the thumb and fingers. Exert pressure just proximal to the heads of the first and fifth metatarsals. *****Tenderness along the posterior medial malleolus is seen in posterior tibial tendinitis. *****Tenderness on compression is an early sign of RA. Acute inflammation of the first MTP joint is common in gout. Palpate the heads of the five metatarsals and the grooves between them with your thumb and index finger (Fig. 16-89). Place your thumb on the dorsum of the foot and your index finger on the plantar surface. *****Pain and tenderness, called metatarsalgia, occurs in trauma, arthritis, and vascular compromise. Tenderness over the third and fourth metatarsal heads on the plantar surface is suspicious for Morton neuroma *****Forefoot abnormalities like hallux val- gus, metatarsalgia, and Morton neuroma are more common with wear of high- heeled shoes with narrow toe boxes.

Inspection/palpation of Shoulder

-Inspection: *Note any swelling, deformity, muscle atrophy or fasciculations (fine tremors of the muscles), or abnormal positioning. ****Scoliosis may cause elevation of one shoulder. With anterior dislocation of the shoulder, the rounded lateral aspect of the shoulder appears flattened. ****Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear within 2 to 3 weeks of a rotator cuff tear; *Look for swelling of the joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Survey the entire upper extremity for color change, skin alteration, or unusual bony contours. *****Swelling from synovial fluid accumu- lation is rare and must be significant before the glenohumeral joint cap- sule appears distended. Swelling in the acromioclavicular joint is easier to detect as the joint is more superficial. Palpation: -Begin by palpating the bony contours and structures of the shoulder, then palpate any area of pain. Do the clavicle, the sternoclavicular jt, scapula, acromion, acromioclavicular joint, coracoid process, greater tubercle (C), where the SITS muscles insert, palpate the biceps tendon in the intertubercular bicipital groove, by keeping your thumb on the coracoid process and your fingers on the lateral aspect of the humerus. Remove your index finger and place it halfway between the coracoid process and the greater tubercle on the anterior sur- face of the arm. As you check for tendon tenderness, rolling the tendon under the fingertips may be helpful. *To examine the subacromial and subdeltoid bursae and the SITS muscles, first passively extend the humerus by lifting the elbow posteriorly, which rotates these structures so that they are anterior to the acromion. Palpate carefully over the subacromial and subdeltoid bursae *****Localized tenderness points to subacromial or subdeltoid bursitis, degenerative changes, or calcific deposits in the rotator cuff. Swelling suggests a bursal tear that communicates with the articular cavity. Tenderness over the SITS muscle insertions and inability to abduct the arm above shoulder level occurs in sprains, tears, and tendon rupture of the rotator cuff, most commonly the supraspinatus. -The fibrous articular capsule and the broad flat tendons of the rotator cuff are so closely associated that they must be examined simultaneously. Swelling in the capsule and synovial membrane is often best detected by looking down on the shoulder from above. Palpate the capsule and synovial membrane beneath the anterior and posterior acromion to check for injury or arthritis.

Spine: muscles/joints

-Joints: *slightly movable cartilaginous joints between the vertebral bodies and between the articular facets. Between the vertebral bodies are the intervertebral discs, each consisting of a soft mucoid central core, the nucleus pulposus, rimmed by the tough fibrous tissue of the annulus fibrosis. *Note that the vertebral column angles sharply posterior at the lumbosacral junction and becomes immovable. The mechanical stress at this angulation contributes to the risk for disc herniation and subluxation, or slippage (spondylolisthesis) -Muscles: *The trapezius and latissimus dorsi form the large outer layer of muscles attaching to each side of the spine *They overlie two deeper muscle layers—a layer attaching to the head, neck, and spinous processes (splenius capitis, splenius cervicis, and sacrospinalis) and a layer of smaller intrinsic muscles between vertebrae. Muscles attaching to the anterior surface of the vertebrae, including the psoas muscle and muscles of the abdominal wall, assist with flexion.

Inspection of the Knee

-Learn to examine "the seven structures of the knee": the medial and lateral menisci, the LCL and MCL, the ACL and PCL, and the patellar tendon. The ACL and PCL are not palpable but are tested by specific maneuvers. Palpation and maneuvers of these structures are especially helpful in primary care diagnosis. -Inspection. *Inspect the gait for a smooth rhythmic flow as the patient enters the room. The knee should be extended at heel strike and flexed at all other phases of swing and stance. *****Stumbling or "giving way" of the knee during heel strike suggests quadriceps weakness or abnormal patellar tracking *****Bow-legs (genu varum) and knock- knees (genu valgum) are common. Quadriceps atrophy signals hip girdle weakness in older adults. *Inspect for any loss of the normal hollows around the patella, a sign of swelling in the knee joint and suprapatellar pouch; note any other swelling in or around the knee. ********Swelling over the patella occurs in prepatellar bursitis (housemaid's knee). Swelling over the tibial tuber- cle suggests infrapatellar or, if more medial, anserine bursitis. -Palpation: *Ask the patient to sit on the edge of the examining table with the knees in flexion *The Tibiofemoral Joint. Palpate the tibiofemoral joint. Facing the knee, place your thumbs in the soft tissue depressions on either side of the patellar tendon. Identify the groove of the tibiofemoral joint. Note that the inferior pole of the patella lies at the tibiofemoral joint line. As you press your thumbs downward, you can feel the edge of the tibial plateau. Follow it medially, then laterally, until you are stopped by the converging femur and tibia. tenderness is common after trauma and requires prompt further evaluation *Medial and lateral joint compartments: MCL and LCL. Palpate the medial and lateral joint compartments of the tibiofemoral joint with the knee flexed on the examining table to approximately 90° *Medial compartment. Medially, move your thumbs upward to palpate the medial femoral condyle. The adductor tubercle is posterior to the me- dial femoral condyle. Move your thumbs downward to palpate the me- dial tibial plateau.

Abduction (or Valgus) Stress Test.

-Medial Collateral Ligament (MCL) test -With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). *****Pain or a gap in the medial joint line is a positive test for an MCL injury

Additional Structures- Knee

-Menisci: The medial and lateral menisci cushion the action of the femur on the tibia. These crescent-shaped fibro- cartilaginous discs add a cup-like surface to the otherwise flat tibial plateau. -Ligaments: The medial collateral ligament (MCL), not easily palpable, is a broad, flat ligament connecting the medial fem- oral epicondyle to the medial condyle of the tibia. The medial portion of the MCL also attaches to the me- dial meniscus. -The lateral collateral ligament (LCL) connects the lateral femoral epicondyle and the head of the fibula. -The MCL and LCL provide medial and lateral stability to the knee joint. -The ACL crosses obliquely from the anterior medial tibia to the lateral femoral condyle, preventing the tibia from sliding forward on the femur. -The posterior cruciate ligament (PCL) crosses from the posterior tibia and lateral meniscus to the medial femoral condyle, preventing the tibia from slip- ping backward on the femur. Although the ACL and PCL lie within the knee joint so are not palpable, they are nonetheless crucial to the anteroposterior stability of the knee.

Preventing Falls.

-More than one in three adults over age 65 years fall each year. Falls are the leading cause of fatal and nonfatal injuries among older adults -Risk factors for falls include increasing age, impaired gait and balance, postural hypotension, loss of strength, medication use, comorbid illness, depression, cognitive impairment, and visual deficits. *****Once injured, articular cartilage is replaced by less resilient fibrocarti- lage, increasing risk of pain and OA. -The USPSTF gives a grade B recommendation for providing exercise or physi- cal therapy and/or vitamin D supplementation to prevent falls among at-risk community-dwelling adults ages ≥65 years.

Muscle Groups and Additional Structures of foot/ankle

-Movement at the ankle (tibiotalar) joint is limited to dorsiflexion and plantar flexion. -Plantar flexion is powered by the gastrocnemius, the posterior tibial muscle, and the toe flexors. Their tendons run behind the malleoli. The dorsiflexors include the anterior tibial muscle and the toe extensors. They lie prominently on the anterior surface, or dorsum, of the ankle, anterior to the malleoli. -Ligaments extend from each malleolus onto the foot. Medially, the triangle-shaped deltoid ligament fans out from the inferior surface of the medial malleolus to the talus and proximal tarsal bones, protecting against stress from eversion (heel bows outward). -Laterally, the three ligaments are less substantial, with higher risk for injury: the anterior talofibular ligament, most at risk in injury from inversion (heel bows inward) injuries; the calcaneofibular ligament; and the posterior talofibular ligament. The strong Achilles tendon attaches the gastrocnemius and soleus muscles to the posterior calcaneus. The plantar fascia inserts on the medial tubercle of the calcaneus.

Neck Pain.

-Neck pain is also common. If the patient reports neck trauma, common in motor vehicle accidents, ask about neck tenderness and consider clinical decision rules that identify risk of cervical cord injury. The NEXUS criteria and the Canadian C-Spine Rule are highly sensitive and specific for establishing a low probability of cervical spine injury. ***The NEXUS criteria are normal alert- ness, no posterior midline cervical spine tenderness, no focal neurologic deficits, no evidence of intoxication, and no painful distracting injury. The Canadian C-Spine Rule includes age, mechanism of injury, low risk factors allowing assessment of range of motion, and testing of neck rotation. *Persistent pain after blunt trauma or a collision warrants further evaluation. *Neck pain is usually self-limited, but it is important to ask about radiation into the arm or scapular area, arm weakness, numbness, or paresthesias. Elicit any of the "red flag" symptoms:

The Suprapatellar Pouch, Prepatellar Bursa, and Anserine Bursa

-Palpate Palpate for any thickening or swelling in the suprapatellar pouch and along the margins of the patella. Start 10 cm above the superior border of the patella, well above the pouch, and feel the soft tissues between your thumb and fingers. Move your hand distally in progressive steps, trying to identify the pouch. Continue your palpation along the sides of the patella. Note any tenderness or increased warmth. *****Swelling around the patella points to synovial thickening or effusion of the knee joint ******Thickening, bogginess, or warmth occurs with synovitis and nontender effusions from OA. *Check three other bursae for bogginess or swelling. Palpate the prepatellar bursa. Palpate over the anserine bursa on the posteromedial side of the knee between the MCL and the tendons inserting on the medial tibial and plateau. On the posterior surface, with the leg extended, check the medial aspect of the popliteal fossa. ******Prepatellar bursitis is triggered by excessive kneeling; anserine bursitis from running, valgus knee deformity, or OA; and a popliteal or "Baker" cyst from distention of the gastrocnemius semimembranosus bursa from under- lying arthritis or trauma.

Gastroecnemius, soleus, and achilles tendon

-Palpate the gastrocnemius and soleus muscles on the posterior lower leg. Their common tendon, the Achilles, is palpable from about the lower third of the calf to its insertion on the calcaneus. -To test the integrity of the Achilles tendon, place the patient prone with the knee and ankle flexed at 90°, or alternatively, ask the patient to kneel on a chair. Squeeze the calf and watch for plantar flexion at the ankle. ********A defect in the muscles, tenderness, and swelling signal a ruptured Achilles tendon; tenderness and thickening of the tendon, at times with a protuber- ant posterolateral bony process of the calcaneus, suggests Achilles tendinitis. *********Absent plantar flexion is a positive test for Achilles tendon rupture. Sudden severe pain "like a gunshot," an ecchy- mosis from the calf into the heel, and a flat-footed gait with absent "toe-off" may also be present.

Palpation of the knee

-Palpation: *Ask the patient to sit on the edge of the examining table with the knees in flexion *The Tibiofemoral Joint. Palpate the tibiofemoral joint. Facing the knee, place your thumbs in the soft tissue depressions on either side of the patellar tendon. Identify the groove of the tibiofemoral joint. Note that the inferior pole of the patella lies at the tibiofemoral joint line. As you press your thumbs downward, you can feel the edge of the tibial plateau. Follow it medially, then laterally, until you are stopped by the converging femur and tibia. By moving your thumbs up- ward toward the midline to the top of the patella, you can follow the articulating surface of the femur and identify the margins of the joint. ******Bony enlargement at the joint margins, genu varum deformity, and stiffness lasting ≤30 minutes are typical findings in OA *Palpate the medial meniscus. Palpate the medial meniscus. Press on the medial soft tissue depression along the upper edge of the tibial plateau with the tibia slightly internally rotated. Place the knee in slight flexion and palpate the lateral meniscus along the lateral joint line. ******A medial meniscus tear with joint line point tenderness is common after trauma and requires prompt further evaluation. *Medial and lateral joint compartments:MCL and LCL. Palpate the medial and lateral joint compartments of the tibiofemoral joint with the knee flexed on the examining table to approximately 90°. Pay special at- tention to any areas of pain or tenderness. *Medial compartment. Medially, move your thumbs upward to pal- pate the medial femoral condyle. The adductor tubercle is posterior to the me- dial femoral condyle. Move your thumbs downward to palpate the medial tibial plateau. Also medially, palpate along the joint line and identify the MCL, which con- nects the medial epicondyle of the femur to the medial condyle and superior medial surface of the tibia. Palpate along this broad, flat ligament from its origin to insertion *Lateral compartment. Lateral to the patellar tendon, move your thumbs upward to palpate the lateral femoral condyle and downward to palpate the lateral tibial plateau. When the knee is flexed, the femoral epicondyles are lateral to the femoral condyles. *****MCL tenderness after injury is suspicious for an MCL tear; LCL injuries are less frequent. *Also on the lateral surface, ask the patient to cross one leg so that the ankle rests on the opposite knee and find the LCL, a firm cord that runs from the lateral femoral epicondyle to the head of the fibula. *Patellofemoral compartment: patellar tendon. Palpate the patellofemoral compartment. Locate the patella and trace the patellar tendon distally until you palpate the tibial tuberosity. Ask the patient to extend the knee to make sure the patellar tendon is intact. *****Tenderness over the tendon or inability to extend the knee suggests a partial or complete tear of the patellar tendon. *With the patient supine and the knee extended, compress the patella against the underlying femur, and gently move it medially and laterally, assessing for crepitus and pain. Ask the patient to tighten the quadriceps as the patella moves distally in the trochlear groove. Check for a smooth sliding motion (the patellofemoral grinding test). ******Pain and crepitus arise from the roughened undersurface of the patella as it articulates with the femur. Similar pain may occur when using the stairs, or getting up from a chair. ******Pain with compression and patellar movement during quadriceps contraction occurs in chondromalacia. Two of three findings are most diag- nostic of the patellofemoral pain syndrome: pain with quadriceps contraction; pain with squatting; and pain with palpation of the posterome- dial/or lateral patellar border.

Posterior Drawer Sign.

-Posterior Cruciate Ligament (PCL) -Position the patient and place your hands in the positions described for the anterior drawer test. Push the tibia posteri- orly and observe the degree of back- ward movement in the femur *****If the proximal tibia falls back, this is a positive test for PCL injury, Isolated PCL tears are less common, usually resulting from a direct blow to the proximal tibia.

Range of Motion and Maneuvers- Neck

-Range of Motion: Neck. *most mobile portion of the spine, remarkable for its seven fragile vertebrae. Flexion and extension occur primarily between the skull and C1, the atlas; rota- tion at C1-C2, the axis; and lateral bending at C2-C7. *****Limited range of motion is caused by stiffness from arthritis, pain from trauma, overuse, and muscle spasm from torticollis. ******Assess any complaints or findings of neck, shoulder, or arm pain, numb- ness, or weakness for possible cervical cord or nerve root compression -Flexion : Sternocleidomastoid, scalene, prevertebral muscles. "Bring your chin to your chest." -Extension: Splenius capitis and cervicis, small intrinsic neck muscles. "Look up at the ceiling -Rotation : Sternocleidomastoid, small intrinsic neck muscles, "Look over one shoulder, and then the other." -Lateral Bending: Scalenes and small intrinsic neck muscles, "Bring your ear to your shoulder. *****Tenderness at C1-C2 in RA is suspicious for possible subluxation and high cervi- cal cord compression and warrants prompt additional assessment.

Knee Bursae

-Several bursae lie near the knee. The prepatellar bursa lies between the patella and the overlying skin. The anserine bursa lies 1 to 2 cm below the knee joint on the medial surface, proximal and medial to the attachments of the medial hamstring muscles on the proximal tibia. It cannot be palpated due to these overlying tendons. Now identify the large semimembranosus bursa that communicates with the joint cavity, also on the posterior and medial surfaces of the knee.

Additional Structures of hand/wrist

-Soft tissue structures, especially tendons and tendon sheaths, are especially important to movement of the wrist and hand. -Six extensor tendons and two flexor tendons pass across the wrist and hand to insert on the fingers. Through much of their course these tendons travel in tunnel-like sheaths, generally palpable only when swollen or inflamed. -Carpal tunnel: The channel contains the sheath and flexor ten- dons of the forearm muscles and the median nerve. -Holding the tendons and tendon sheath in place is a transverse ligament, the flexor retinaculum. The median nerve lies between the flexor retinaculum and the tendon sheath. The median nerve provides sensa- tion to the palm and the palmar sur- face of most of the thumb, the second and third digits, and half of the fourth digit. It also innervates the thumb muscles of flexion, abduction, and opposition.

Types of synovial joints

-Spheroidal joints: have a ball-and-socket configuration—a rounded, convex surface articulating with a concave cuplike cavity, allowing a wide range of rotatory movement, as in the shoulder and hip -Hinge joints: are flat, planar, or slightly curved, allowing only a gliding motion in a single plane, as in flexion and extension of the digits. Interphalangeal joints of hand and foot; elbow -Condylar Joints: Condylar joints, such as the knee, have articulating surfaces that are convex or concave. These joints allow flexion, extension, rotation, and motion in the coronal plane. temporomandibular joint

Palpation Tests for Knee Joint Effusions

-The bulge sign (for minor effusions). With the knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, displacing or "milking" fluid downward. Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area. Tap the knee just behind the lateral margin of the patella with the right hand. *****A fluid wave or bulge on the medial side between the patella and the femur is a positive test for effusion. *The balloon sign (for major effusions). Place the thumb and index finger of your right hand on each side of the patella; with the left hand, compress the suprapatellar pouch against the femur. Palpate for fluid ejected or "balloon- ing" into the spaces next to the patella under your right thumb and index finger. *******A palpable fluid wave is a positive test or "balloon sign." A palpable returning fluid wave into the suprapatellar pouch further confirms a major effusion, present in knee fractures *Balloting the patella (for major effusions). To assess large effusions, you can also compress the suprapatellar pouch and "ballotte" or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch ********A palpable fluid wave returning into the pouch is also a positive test for a major effusion. ********A palpable patellar click with compression may also occur, but yields more false positives

Shoulder anatomy

-The glenohumeral joint of the shoulder is distinguished by wide- ranging movement in all directions. This joint is largely uninhibited by bony structures. essentially dangles from the scapula, attached by the joint capsule, the intra-articular capsular ligaments, the glenoid labrum, and a meshwork of muscles and tendons. -mobility from three joints, three large bones, and three principal muscle groups, often referred to as the shoulder girdle. These structures are viewed as dynamic stabilizers, which are capable of movement, or static stabilizers, which are incapable of movement. *Dynamic stabilizers: (consist of the SITS muscles of the rotator cuff (Supra-spinatus, Infraspinatus, Teres minor, and Subscapularis), which move the humerus and compress and stabilize the humeral head within the glenoid cavity.) *Static stabalizers: bony structures of the shoulder girdle, the labrum, the articular capsule, and the glenohumeral ligaments. The joint capsule is strength- ened by tendons of the rotator cuff and glenohumeral ligaments, adding to joint stability. -Bony structures: The bony structures of the shoulder include the humerus, the clavicle, and the scapula. The scapula is anchored to the axial skeleton only by the sternoclavicular joint and inserting muscles, often called the scapulothoracic articulation because it is not a true joint.

Joints of the shoulder

-The glenohumeral joint: In this joint, the head of the humerus articulates with the shallow glenoid fossa of the scapula. This joint is deeply situated and normally not palpable. It is a ball-and-socket joint, allowing the arm its wide arc of movement—flexion, extension, abduction (movement away from the trunk), adduction (movement toward the trunk), rotation, and circumduction. -The sternoclavicular joint: The convex medial end of the clavicle articulates with the concave hollow in the upper sternum. -The acromioclavicular joint: The lateral end of the clavicle articulates with the acromion process of the scapula.

The Hip overview, joints, bony structures

-The hip joint is deeply embedded in the pelvis and is notable for its strength, stability, and wide range of motion. -It is a ball-and-socket joint; note how the rounded head of the femur articulates with the cup-like cavity of the acetabulum. Because of its overlying muscles and depth, the hip joint is not readily palpable. Review the bones of the pelvis—the acetabulum, the ilium, and the ischium—and the connection inferiorly at the symphysis pubis and posteriorly with the sacroiliac bone. -On the anterior surface of the hip, locate the following bony structures: *The iliac crest at the level of L4 *The iliac tubercle *The anterior superior iliac spine *The greater trochanter *The pubic tubercle -On the posterior surface of the hip, locate the fol- lowing: ■ The posterior superior iliac spine ■ The greater trochanter ■ The ischial tuberosity ■ The sacro iliac joint

-Calcium and Vitamin D:

-Treating Osteoporosis *Calcium, the most abundant mineral in the body, is essential for bone health, muscle function, nerve transmission, vascular function, and intracellular signaling and hormonal secretion. *Serum calcium is tightly regulated. The body relies on bone tissue, and not dietary calcium, to maintain stable concentrations in blood, muscle, and intracellular fluid. Bone is subject to constant remodeling from calcium deposition and resorption; the balance between these processes varies dur- ing the different stages of life. *Humans acquire vitamin D from sunlight, food, and dietary supplements. Without vitamin D, less than 25% of dietary calcium is absorbed. Parathyroid hormone (PTH) enhances renal tubular absorption of calcium and stimulates the conversion of 25[OH]D to 1,25[OH]2D. PTH also activates osteoblasts, which lay down new bone matrix, and indirectly stimulates osteoclasts, which dissolve bone matrix. There are two main forms of calcium supplements, calcium carbonate and calcium citrate.

The Knee-Overview, bones,

-The knee joint is the largest joint in the body. It is a hinge joint involving three bones: the femur, the tibia, and the patella (or knee cap), with three articular surfaces, two between the femur and the tibia and one between the femur and the patella. -There is no inherent stability in the knee joint itself, making it dependent on four ligaments to hold its articulating femur and tibia in place. Bones: -On the medial surface, identify the adductor tubercle, the medial epicondyle of the femur, and the medial condyle of the tibia -On the anterior surface, identifythe patella, which rests on the an-terior articulating surface of thefemur midway between the epi-condyles, embedded in the ten-don of the quadriceps muscle. -On the lateral surface, find the lateral epicondyle of the femur, the lateral condyle of the tibia, and the head of the fibula. Joints: -Two condylar tibiofemoral joints are formed by the convex curves of the medial and lateral condyles of the femur as they articulate with the concave condyles of the tibia. The third articular surface is the patellofemoral joint. The patella slides on the groove of the anterior aspect of the distal femur, called the trochlear groove, during flexion and extension of the knee. *****Problems with patellar tracking, for example, in patients with shallower grooves, especially women, can lead to arthritis, anterior knee pain, and patellar dislocation. Muscle Groups: Powerful muscles move and support the knee. The quadriceps femoris extends the knee, covering the anterior, medial, and lateral aspects of the thigh. The hamstring muscles lie on the posterior aspect of the thigh and flex the knee. ******In women, quadriceps contraction often exerts a more lateral pull (Q angle) that alters patellar tracking, contributing to anterior knee pain

ROM test for shoulder girdle

-The six motions of the shoulder girdle are flexion, extension, abduction, adduction, and internal and external rotation ****Restricted range of motion occurs in bursitis, capsulitis, rotator cuff tears or sprains, and tendinitis. *Standing in front of the patient, watch for smooth fluid movement as the patient performs .Test muscle strength. *****Note that to test pure glenohumeral motion, the patient should raise the arms to shoulder level at 90°, with palms facing down. To test scapulo- thoracic motion, the patient should turn the palms up and raise the arms an additional 60°. The final 30° tests combined glenohumeral and scapulothoracic motion. -Flexion: Principal Muscles Affecting Movement: Anterior deltoid, pectoralis major (clavicular head), coracobrachialis, biceps brachii Patient Instructions: "Raise your arms in front of you and over- head." -Extension: Principal Muscles Affecting Movement: Latissimus dorsi, teres major, posterior deltoid, triceps brachii (long head) Patient Instructions: "Raise your arms behind you." -Abduction: Principal Muscles Affecting Movement: Supraspinatus, middle deltoid, serratus anterior (via upward rotation of the scapula) Patient Instructions: "Raise your arms out to the side and over- head. -Adduction: Principal Muscles Affecting Movement: Pectoralis major, coracobrachialis, latissimus dorsi, teres major, subscapularis Patient Instructions: "Cross your arm in front of your body." -Internal rotation: Patient Instructions: Principal Muscles Affecting Movement Subscapularis, anteriordeltoid, pectoralis, major, teres major, latissimus dorsi "Place one hand behind your back and touch your shoulder blade." Identify the highest midline spinous pro- cess the patient is able to reach -External rotation: Principal Muscles Affecting Movement: Infraspinatus, teresminor, posterior, deltoid Patient Instructions: "Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the ceiling." OR "Place one hand behind your neck or head as if you are brushing your hair.

The Wrist and Hands: overview, bones, joints

-The wrist includes the distal radius and ulna and eight small carpal bones Joints: *Wrist joints. The wrist joints include the radiocarpal or wrist joint, the distal radioulnar joint, and the intercarpal joints. The joint capsule, articular disc, and synovial membrane of the wrist join the radius to the ulna and to the proximal carpal bones. On the dorsum of the wrist, locate the groove of the radiocarpal joint. This joint provides most of the flexion and extension at the wrist because the ulna does not articulate directly with the carpal bones. *Hand joints. The joints of the hand include the metacarpophalangeal joints (MCPs), the proximal interphalangeal joints (PIPs), and the distal interphalangeal joints (DIPs). Flex the hand and find the groove marking the MCP joint of each finger. It is distal to the knuckle and is best felt on either side of the extensor tendon. *****Degenerative changes at the first carpometacarpal joint of the thumb are more common in women. -Muscle Groups. *Wrist flexion arises from the two carpal muscles, located on the radial and ulnar surfaces. Two radial and one ulnar muscle provide wrist extension. Supination and pronation are powered by muscle contraction in the forearm. *The thumb is powered by three muscles that form the thenar eminence and provide flexion, abduction, and opposition. The muscles of extension are at the base of the thumb along the radial margin. Movement in the digits depends on action of the flexor and extensor tendons of muscles in the forearm and wrist. *The intrinsic muscles of the hand attaching to the metacarpal bones are involved in flexion (lumbricals), abduction (dorsal interossei), and adduction (palmar inter- ossei) of the fingers.

Muscle groups of shoulder

-Three groups of muscles attach at the shoulder: *The Scapulohumeral Group (SITS): The scapulohumeral group rotates the shoulder laterally -Supraspinatus—runs above the glenohumeral joint; inserts on the greater tubercle -Infraspinatus and teresminor—cross the glenohumeral joint posteriorly; insert on the greater tubercle -Subscapularis—originates on the anterior surface of the scapula and crosses the joint anteriorly; inserts on the lesser tubercle *The Axioscapular Group: This group attaches the scapula to the trunk and includes the trapezius, rhomboids, serratus anterior, and levator scapulae. These muscles rotate the scapula and pull the shoulder posteriorly. *The Axiohumeral Group. This group attaches the humerus to the trunk and includes the pectoralis major and minor and the latissimus dorsi. These muscles rotate the shoulder internally. *The biceps and triceps, which connect the scapula to the bones of the forearm, are also involved in shoulder movement, especially forward flexion (biceps) and extension (triceps). *Also important toshoulder movement are the articular capsule and bursae. The capsule is lined by a synovial membrane with two outpouchings—the subscapular bursa and the synovial sheath of the tendon of the long head of the biceps. *The principal bursa of the shoulder is the subacromialbursa, positioned between the acromion and the head ofthe humerus and overlying the supraspinatus tendon.Abduction of the shoulder compresses this bursa. Normally, the supraspinatus tendon and the subacromialbursa are not palpable. However, if the bursal surfacesare inflamed (subacromial bursitis), there may be tender-ness just below the tip of the acromion, pain withabduction and rotation, and loss of smooth movement.

Antiresorptive and Anabolic Agents.

-Treating Osteoporosis -Antiresorptive agents inhibit osteoclast activity and slow bone remodeling, allowing better mineralization of bone matrix and stabilization of the trabecular microarchitecture -These agents include bisphosphonates, selective estrogen-receptor modulators (SERMs), cal- citonin, and postmenopausal estrogen. Bisphosphonates are considered the first- line therapy for osteoporosis. -Estrogen therapy is now contraindicated due to associated risks of breast cancer and vascular thrombosis.47 Bisphosphonates have been linked to rare risks of osteonecrosis of the jaw and atypical femur fractures, and SERMs increase the risk for thromboembolic events. -Anabolic agents such as PTH stimulate bone formation by acting primarily on osteoblasts but require subcutaneous administration and monitoring for hypercalcemia. PTH is reserved for patients with severe osteoporosis (T scores < −3.5 or < −2.5 with a fragility fracture) or those who have failed or not tolerated other therapies.

McMurray Test

-Used to test Medial Meniscus and Lateral Meniscus With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in external rotation. The same maneuver with internal rota- tion of the foot stresses the lateral meniscus. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear. *****A palpable click or pop along the medial or lateral joint line is a positive test for a tear of the posterior portion of the medial meniscus (positive LR of 4.5).57 The tear may displace meniscal tissue, causing "locking" on full knee extension.

Maneuvers for Examining the Knee

-You will often need to test ligamentous stability and integrity of the medial and lateral menisci, the MCL and LCL, the patellar tendon, and the ACL and PCL (not palpable), particularly when there is a history of trau- ma or knee pain. Always examine both knees and compare findings. ****ACL tears are notably more frequent in women, attributed to ligamentous laxity related to estrogen cycling and to differences in anatomy and neuro- muscular control. ACL injury preven- tion programs are now common. -Medial Meniscus and Lateral Meniscus: McMurray Test. -Medial Collateral Ligament (MCL): Abduction (or Valgus) Stress Test -Lateral Collateral Ligament (LCL). Adduction (or Varus) Stress Test -Anterior Cruciate Ligament (ACL), Anterior Drawer Sign, Lachman Test -Posterior Cruciate Ligament (PCL), Posterior Drawer Sign.

The Spine- bony structures

-concave curves of the cervical and lumbar spine and the convex curves of the thoracic and sacrococcygeal spine help distribute upper body weight to the pelvis and lower extremities and cushion the concussive impact of walking or running. *Bony structures: -contains 24 vertebrae stacked on the sacrum and coccyx. Anteriorly, the vertebral body supports weight bearing. The posterior vertebral arch encloses the spinal cord -spinous process projecting posteriorly in the midline and the two transverse processes at the junction of the pedicle and the lamina. Muscles attach at these processes. -The articular processes—two on each side of the vertebra, one facing up and one facing down, at the junction of the pedicles and laminae, often called articular facets. -The vertebral foramen, which en- closes the spinal cord, the intervertebral foramen, formed by the inferior and superior articulating process of adjacent vertebrae, creating a channel for the spinal nerve roots; and in the cervical vertebrae, the transverse foramen for the vertebral artery.

Temporomandibular Joint Exam

-condylar synovial joint -most active joint in the body -formed by the fossa and articular tubercle of the temporal bone and the con- dyle of the mandible. It lies midway between the external acoustic meatus and the zygomatic arch. *Muscle Groups and Additional Structures: -opening the mouth are the external pterygoids -Closing the mouth are the muscles innervated by cranial nerve V, the trigeminal nerve— the masseter, the temporalis, and the internal pterygoids *Inspection and Palpation. -Inspect the face for symmetry. Inspect the TMJ for swelling or redness. Swelling may appear as a rounded bulge approxi- mately 0.5 cm anterior to the external auditory meatus. ****Facial asymmetry is seen in TMJ disorders, a category of orofacial pain with multifactorial etiologies; typically, there is unilateral chronic pain with chewing, jaw clenching, or teeth grind- ing, often associated with stress and accompanied by headache. Pain with chewing also occurs in trigeminal neuralgia and temporal arteritis. -Check for smooth range of motion; note any swelling or tenderness. Snapping or clicking may be felt or heard in normal people. ***Swelling, tenderness, and decreased range of motion signal TMJ inflamma- tion or arthritis. ****TMJ dislocation can be caused by trauma. ****Palpable crepitus or clicking is pres- ent in poor occlusion, meniscus injury, or synovial swelling from trauma. *****In TMJ syndrome, there is pain and tenderness with palpation. -Palpate the muscles of mastication: ■ The masseters, externally at the angle of the mandible ■ The temporal muscles, externally during clenching and relaxation of the jaw ■ The pterygoid muscles, internally between the tonsillar pillars at the mandible *Range of Motion and Maneuvers. -TMJ has glide and hinge motions in its upper and lower portions, respectively. Grinding or chewing consists primarily of gliding movements in the upper compartments. -Range of motion is threefold: ask the patient to demonstrate opening and closing, protrusion and retraction (by jutting the mandible forward), and lateral, or side- to-side, motion. Normally, as the mouth is opened wide, three fingers can be inserted between the incisors. During normal protrusion of the jaw, the bottom teeth can be placed in front of the upper teeth.

Low back pain

-low back pain is one of the most common reasons for office visits. -There are numerous clinical guidelines, but most categorize low back pain into three groups: nonspecific (>90%), nerve root entrapment with radiculopathy or spinal stenosis (∼5%), and pain from a specific underlying disease (1% to 2%).4,20 Note that the term "nonspecific low back pain" is preferred to "sprain" or "strain." *****Nonspecific low back pain is usually from musculoligamentous injuries and age-related degenerative pro- cesses of the intervertebral discs and facet joints. -Determine if the pain is on the midline, over the vertebrae, or off the midline. ****For midline back pain, diagnoses include musculoligamentous injury; disc herniation; vertebral collapse; spinal cord metastases; and, rarely, epidural abscess. For pain off the midline, assess for muscle strain, sacroiliitis, trochanteric bursitis, sciatica, and hip arthritis as well as for renal condi- tions like pyelonephritis or stones. -Is there radiation into the buttock or lower extremity? Is there any associated numbness or paresthesias? ****Sciatica is radicular gluteal and poste- rior leg pain in the S1 distribution that increases with cough or Valsalva ; 85% of cases are associated with a disc disorder, usually at L4-L5 or L5-S1.21 Leg pain that resolves with rest and/or lumbar forward flexion occurs in spinal stenosis. -Importantly, is there any associated bladder or bowel dysfunction? ******Consider cauda equina syndrome from an S2-S4 midline disc or tumor if there is bowel or bladder dysfunction (usually urinary retention with over- flow incontinence), especially if there is saddle anesthesia or perineal numbness. Pursue immediate imaging and surgical evaluation Red flags in back pain (underlying conditions): ● Age <20 years or >50 years ● History of cancer ● Unexplained weight loss, fever, or decline in general health ● Pain lasting more than 1 month or not responding to treatment ● Pain at night or present at rest ● History of intravenous drug use, addiction, or immunosuppression ● Presence of active infection or human immunodeficiency virus (HIV) infection ● Long-term steroid therapy ● Saddle anesthesia, bladder or bowel incontinence ● Neurologic symptoms or progressive neurologic deficit ****Studies show that psychosocial factors, now called "yellow flags," strongly affect the course of low back pain. Ask about anxiety, depres- sion, and work stress. Assess any maladaptive coping (avoiding work, movement, or other activities for fear of causing back damage), inappropriate fears or beliefs, or tendency to somatization.

The Elbow

-three articulations: the humer- oulnar joint, the radiohumeral joint, and the radioulnar joint. All three share a large common articular cavity and an extensive synovial lining. -Muscle Groups and Additional Structures. *Muscles traversing the elbow include the biceps and brachioradialis (flexion), the brachialis, the triceps (extension), the pronator teres (pronation), and the supinator (supination *Note the location of the olecranon bursa between the olecranon process and the skin (Fig. 16-23). The bursa is not normally palpable but swells and becomes tender when inflamed. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecra- non process. The radial nerve is adjacent to the lateral epicondyle. On the ventral forearm, the median nerve is just medial to the brachial artery in the antecubital fossa. -Techniques of Examination: *Inspection. >Support the patient's forearm with your opposite hand so that the elbow is flexed to about 70°. Identify the medial and lateral epicondyles and the olecranon process of the ulna. Note any nodules or swelling. ****Swelling over the olecranon process is suspicious for olecranon bursitis; inflammation or synovial fluid suggests arthritis. *Palpation. >Palpate the olecranon process and press over the epicondyles for tenderness. Palpate the grooves between the epicondyles and the olecranon process, where the synovium is most easily examined. Nor- mally the synovium and olecranon bursae are not palpable ******Tenderness distal to the epicondyle is common in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (pitcher's or golfer's elbow). *Range of Motion and Maneuvers: Range of motion includes flexion and extension at the elbow and pronation and supination of the forearm, which also move the wrist and hand -Flexion: Biceps brachii, brachialis, brachioradialis, "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." ******After injury, preservation of active range of motion and full elbow extension makes fracture highly unlikely. Tenderness over the radial head, olecranon, or medial epicondyle and bruising, plus absent elbow extension, may improve these test characteristics. Full elbow extension also makes intra-articular effusion or hemarthrosis unlikely.

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, especially if pain or trauma 4. Assess any areas of inflammation, especially tenderness, swelling, warmth, redness *Your examination should be systematic. Include inspection, palpation of bony structures and related joint and soft tissue structures, assessment of range of motion, and special maneuvers to test specific movements. Recall that the ana- tomical shape of each joint determines its range of motion. There are two phases to range of motion: active (by the patient) and passive (by the examiner).

Wrists: Range of Motion and Maneuvers

Flexion : Flexor carpi radialis, flexor carpi ulnaris. "With palms down, point your fingers toward the floor." Extension: Extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis. "With palms down, point your fingers toward the ceiling." Adduction (radial deviation): Flexor carpi ulnaris. "With palms down, bring your fingers toward the midline Abduction (ulnar deviation): Flexor carpi radialis. "With palms down, bring your fingers away from the midline." ****Arthritis, tenosynovitis, and Dupuytren contracture all impair range of motion -Hand Grip. Test hand grip strength by ask- ing the patient to grasp your second and third fingers. This tests function of wrist joints, the finger flexors, and the intrinsic muscles and joints of the hand. *****Decreased grip strength is a positive test for weakness of the finger flexors and/or intrinsic muscles of the hand. It also results from inflammatory or degenerative arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy. Grip weakness plus wrist pain are often present in de Quervain tenosynovitis. -Thumb Movement. To test thumb function, ask the patient to grasp the thumb against the palm and then move the wrist toward the midline in ulnar de- viation (sometimes called the Finkelstein test) *****Pain during this maneuver identifies de Quervain tenosynovitis from inflam- mation of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths. **********Weakness on thumb abduction is a positive test. The abductor pollicis longus is innervated only by the median nerve. -Carpal Tunnel Syndrome—Thumb Abduction, Tinel Test, and Phalen Test for Median Nerve Compression. To test thumb abduction, ask the patient to raise the thumb straight up as you apply down- ward resistance *****Combined use of a hand symptom diagram, median nerve territory hypalgesia, and thumb abduction weakness are most consistent with nerve conduction diagnoses of carpal tunnel syndrome ******Tinel and Phalen signs do not reliably predict positive electrodiagnosis of carpal tunnel disease.

The first goal of your evaluation of musculoskeletal disorders is to characterize the patient's complaint in terms of four key features. Is the joint problem:

■ Articular or extra-articular ■ Acute (usually< 6 weeks) or chronic (usually > 12 weeks) ■ Inflammatory or noninflammatory ■ Localized (mono articular) or diffuse (polyarticular)

Joint Anatomy—Important Terms

● Articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone. Articular cartilage is composed of a collagen matrix containing charged ions and water, allowing the cartilage to change shape in response to pressure or load, acting as a cushion for underlying bone. Synovial fluid provides nutrition to the adjacent relatively avascular articular cartilage. ● Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin. ● Ligaments are rope-like bundles of collagen fibrils that connect bone to bone. ● Tendons are collagen fibers connecting muscle to bone. ● Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures. *****Articular disease typically involves swelling and tenderness of the entire joint, crepitus, instability, "locking," or deformity, and limits both active and passive range of motion due to either stiffness or pain *****Extra-articular disease typically involves "point or focal tenderness in regions adjacent to articular structures" and limits active range of motion. Extra-articular disease rarely causes swelling, instability, or joint deformity.

Tips for Successful Examination of the Musculoskeletal System

● 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? *****Acute involvement of only one joint suggests trauma, septic arthritis, or crystalline arthritis. RA is typically polyarticular and symmetrical. *Note any deformities or malalignment of bones or joints. ******Malalignment occurs in Dupuytren contracture, bow-legs (genu varum) or knock-knees (genu valgum). ● Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle atrophy. Note any crepitus, an audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss. This may occur in joints without pain but is more significant when associated with symptoms or signs. *****Look for subcutaneous nodules in RA or rheumatic fever; effusion in trauma; crepitus over inflamed joints in OA or over the inflamed tendon sheaths of tenosynovitis. ● Test range of motion and maneuvers (described for each joint) to demonstrate limitations in range of motion or joint instability from excess mobility of joint ligaments, called ligamentous laxity. ● Finally, test muscle strength to aid in the assessment of joint function ****Decreased range of motion is present in arthritis, joints with tissue inflam- mation or surrounding fibrosis, or bony fixation (ankylosis). Anterior cru- ciate ligament (ACL) laxity occurs in knee trauma; muscle atrophy and weakness is seen in RA. *Inspect and palpate any joints with signs of inflammation.

Assessing the Four Signs of Inflammation

● 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; or (3) soft tissue structures, such as bursae, tendons, and tendon sheaths. *****Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often accompanied by effusion. Palpable joint fluid is present in effusion, tenderness over the tendon sheaths in tendinitis. ● Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with nearby tissues if both joints are involved. *****Increased warmth is seen in arthritis, tendinitis, bursitis, and osteomyelitis. ● Redness. Redness of the overlying skin is the least common sign of inflammation near the joints and is usually seen in more superficial joints like fingers, toes, and knees. *****Redness over a tender joint suggests septic or crystalline arthritis, or possi- bly RA. ● Pain or tenderness. Try to identify the specific anatomic structure that is tender. *****Diffuse tenderness and warmth over a thickened synovium suggest arthritis or infection; focal tenderness suggests injury and trauma.