Common Musculoskeletal Disorders

X-Ray

common initial imaging study

quick+cheap

small amount of radiation

not highest level of detail→2d image

I: obvious fractures/dislocations/arthritis

CT Scan

fast

3d scan

great for trauma

more radiation than xray

I: no MRI
-implanted devices
-retained metal

MRI

highest level of detail+sensitivity in multiple planes

most contrast between different types of soft tissues

slow+expensive

no radiation

CI: implanted devices
retained metal

Ultrasound (US)

technician-dependent

dynamic scanning

no radiation

on-the-fly+procedural guidance

Bone Scan

uses injectable radioactive tracer→extends length of time of the study

shows “hot spots”→areas of increased bony uptake
-related to:

• injury

• damage

• bone weakening

• infection

• hardward complications

• cancer

• etc.

Electromyography (EMG)

evaluates peripheral nerves+muscles

helps to localize neurologic injury

fine needle electrode→inserted into selected muscle→accesses electrical activity at rest+during contraction

I: carpal tunnel syndrome
ulnar neuropathy
lumbar+cervical radiculoapthy
peripheral nerve injury of polyneuropathy

Nerve Conduction Study (NCS)

measures the spread+amplitude of electrical impulses traveling along the nerves

I: neuropathies
demyelination
nerve compression
carpal tunnel syndrome
ulnar neuropathy
lumbar+cervical radiculoapthy
peripheral nerve injury of polyneuropathy

Arthrocentesis

joint aspiration

I+D

incision+drainage/irrigation+debridement

Arthroscopy

minimally invasive surgery

arthroscope camera+arthroscopic tools→small incisions (portals)

Arthroplasty

joint replacement

Arthrodesis

joint fusion

Nongonococcal Septic Arthrirtis

PP: hematogenous seeding of joint
-direct penetrating trauma fxn→rare

• inflammation

• synovitis

• effusion

• abscess formation

• chronic→articular destruction

RF: bacteremia
previous joint damage
prosthetic joints
compromised immunity
injection mxs

E: m/c→s aureus (50%)
MRSA
strep spp
injection mx use/immunosuppression→gram negative spp

CM: acute onset→inflammatory+monoarticular arthritis
acute severe pain
swelling
warmth
±fever
±chills

large weight-bearing joints

• knee

• hip

• wrists

DX:
arthrocentesis

• WBC→over 50k

• 80+% polymophonuclear cells

• positive culture

imaging

• early course→joint effusion

• for difficulty detecting effusion

TX:
NP:
surgical washout

• open

• arthroscopy

MX: PICC line abx x 4-6 wks

C: bony ankylosis (auto-fusion)
articular destruction
bacteremia
further spread of infxn

P: dependent on promptness of tx
causative organism
pt baseline health

Gonococcal Septic Arthritis (Disseminated Gonococcal Infection)

RF: healthy pts
young women during menses
pregnancy

E: m/c→neisseria gonorrheae

2 subsequent patterns

• tenosynovitis
  -wrist
  -fingers
  -ankles
  -toes

• purulent monoarthritis
  -knee
  -wrist
  -ankle
  -elbow

• 2-10 small necrotic pustules
  -palms
  -sole
  -asx

CM:
1-4 days→migratory polyarthralgias

• wrist

• knee

• ankle

• elbow

PE: urogenital
rectal
pharyngeal
-show evidence of infxn

DX: arthrocentesis→difficult to obtain+unreliable results
labs→specify for n gonorrheae

TX: IM/IV ceftriaxone QD→x 24-48 hrs post clinical improvement→PO abx x 7 days
-always check for lcoal trends+resistance patterns

joint drainage→rarely needed

C: significant abx resistance→frequent tx changes

Osteomyelitis

PP:
bone infxn

hematogenous→travels through blood

non-hematogenous:
extension from:

• infectious foci

• open wound

• skin breakdown

• direct inocculation

RF:
hematogenous

• injection mxs

• IV/urinary catheters

• DM

• old

• sickle cell dx

• vascular insufficiency

• pressure sores

non-hematogenous

• orthopedic surgery→joint replacement

• neurosurgery

• trauma surgery

E: s aureus (60%)

CM:
systemic

• ±fever

• ±chills

local

• pain

• swelling

• skin changes
  -cellulitis
  -ertythema
  -drainage

• hematogenous spread→spinal abscesses

DX:
ESR/CRP→elevated
films→abnormal

imaging

• XRay: early dx→negative

• localization→CT/MRI/bone scan

confirmation→culture/biopsy

• blood

• bone

• other contigious foci

TX:
NP:
ortho consult→surgery

• epidural abscess

• spinal cord compression

• focal abscesses

• extensive dx

• abx tx fail

MX: abx x 4-6 weeks minimum
-abx depends on causative agent

C: suppression vs clearance
recurrence
chronic→long standing infxn x months-years

Osteoporosis

PP: loss of bone matrix→reduction in bone integrity/strength→increased fragility+fracture risk

E: white women
50+ y/o
alcohol
tobacco
chronic steroids
chronic PPI therpay

CM:
asx until a fx occurs

• hip

• wrist

• spine

DX: bone dual-energy XRay absorptionmetry (DEXA) scan→T score→u-2.5
secondary causes/concomitant osteomalacia (bone softening)→labs

TX:
NP: calcium supplements
vitamin d supplements
fall prevention
weight-bearing exercise
strength training
fall prevention

MX: spine/hip.pathologic fracture hx→biphosplonates
prolia
high fracturerisk→PTH/analogs
prophx→SERMs
spinal fractures→calcitonin

P: tx→partial reversal→prevention is key

Paget’s Disease

PP: 1+ bony lesions+high bone turnover+disorganized osteoid formation→reduced bone cell activity+enlarged/deformed bones
-disruption of bone remodeling process

RF: UK
genetics

CM:
PANICS
Pain in bone
Arthralgia
Neural deafness/Nerve compression
Increased bone density
Cardiac failure
Skull/Sclerotic vertebra

DX: alkaline phosphatase (ALP)→elevated
imaging: osteolytic/lucent appearance→sclerosis→dense+expanded+deformed bones

TX: asx→close monitoring
sx/singificant bony findings→zoledronic acid
hypocalcemia→calcium+vitamin d supplements

C:
not caught+tx early

• marked deformity

• intractable pain

• increased vascularity→high output HF

skull

• CN palsy

• vascular steal syndrome→neuro sxs

• optic injury

spine

• spinal cord compression

• nerve compression

• vascular steal syndrome→paralysis

P: caught+tx early→good
relapse→common→long-term monitoring+annual alkaline phosphatase levels

Upper Extremity Dx List+Considerations

rotator cuff disorders

adhesive capsulitis

epicondylitis

carpal tunnel syndrome

dupuytren contracture

trigger finger

felon

infectious flexor tenosynovitis

ganglion

dequervain’s tenosynovitis

considerations

• hand dominance

• occupation

• recreational activites

Rotator Cuff Tear

PP:
acute

• fall onto outstretched arm

• aggressive pull on shoulder

chronic

• repetitive injuries

• degenerative dx

E: m/c→supraspinatus
full vs partial thickness

CM: overhand movement→pain/weakness
night pain

PE: decreased AROM
weakness
shoulder specialty testing

DX:
XRay→high riding humeral head (chronic)
tear visualization→MRI
small/partial tears→MR arthrogram

TX:
partial-thickness

• PT

• pain/sx relief→steroid injection

full-thickness

• need surgery
  -rotator cuff tear→arthroscopy→needs significant recovery

• continue to increase in size+sxs

P: recurrence
post-traumatic OA

Subacromial Impingement Syndrome

PP: shallow socket in ball+socket joint→heavy reliance on muscles+ligaments for stability→mechanical inflammation in the subacromial space

E: rotator cuff tears
subacromial bursitis
muscle strength imbalances
poor scapula control
bone spurs

CM: overhead acitvity→pain
sleeping on shoulder→night pain

internal rotation→pain
-putting on jacket
-putting on bra

PE: scapular winging
forward head/shoulder posture
AROM vs PROM
shoulder specialty testing→positive impingement signs

DX: clinical
arthritis/anatomy→XRay
acute tear/tx fail→US/MRI

TX: education
activity modification
PT
pain/sx relief→steroid injections

P: conservative tx→most pts respond well
need to maintain ongoing HEP→prevent recurrence

Adhesive Capsulitis (Frozen Shoulder)

PP:
acute inflammation of shoulder capsule→scarring+remodeling

1. inflammatory phase x 4-6 months

2. freezing phase x 4-6 montsh

3. thawing phase x up to a year

RF/E: 40-65 y/o
perimenopausal women

CM: extremely painful shoulder in all planes of motion+AROM+PROM
strength intact→limited by pain

DX: clinical
r/o arthritis/calcific tendinitis→XRay

TX:
NP: PT
expectation management

surgery

• manipulation

• arthroscopic release

MX: NSAIDS
PO steroids
intra-articular steroid injection

P: self-tx→but still very debilitating
total duration→~24 months
-trauma/encephalopathy→potentially longer

Epicondylitis

PP: tendinosis
tendinopathy
tendon degenernation
not acute inflammation of the epicondyle

E: chronic repetitive overuse→causes microtrauma at tendon insertion

lateral/tennis elbow→wrist extensors
-extensor carpi radialis brevis

medial/golfer’s elbow→wrist flexors
-pronator teres

CM: tenderness over epicondyle
-especially at tendon insertion point

PE: resisted strength testing+passive stretching of tendon muscle/unit→pain
lateral→arm+wrist extension
medial→pronation/wrist flexion

DX: radiograph
tx fail x 3+ months→MRI/US

TX:
NP: 1st line→PT+activity modifications
pain relief→ice
tx fail x 6+ months+consistent imaging findings→surgery

MX: pain relief→NSAIDS
chronic/severe sxs→steroid injection

Ganglion

PP: cystic structure
filled with fluid
contains stalk→connects cyst to joint/tendon sheath

E: m/c→dorsal aspect of wrist
hand

CM: firm
well-circumscribed
fluctuates in size
transiluminate

DX: clinical

TX: fluid aspiration
injection
surgical resection

C: fluid aspiration+injection→high recurrence

De Quervain’s Tenosynovitis

RF: pregnancy
breastfeeding
RA

E: repetitive hand motion
30-50 y/o

CM: pain along the tendon sheath in wrist on thumb side
pain near base of the thumb with catching+snapping
pain gripping/making a fist/pinching

DX: finkelstein test

TX:
NP: rest
splint
tx fail→surgery

MX: corticosteroid injection

Carpal Tunnel Syndrome

PP: compression of medial nerve under carpal ligament inside carpal tunnel→entrapment neuropathy

RF: pregnancy→fluid retention
repetitive use of hands
wrist injuries
rheumatic dx

CM: median N→pain+burning+tingling
extreme flexion of wrist→exacerbation of pain
night pain→wakes pt up at night

PE: tinel sign
phalen test
carpal compression test
late-stage muscle atrophy→thenar eminence

DX:
US→flattening of median nerve under flexor retinaculum
r/o other neuropathic causes+classify severity→EMG/nerve conduction testing

TX:
NP: wrist splinting in neutral position
activity modifications
definitive→carpal tunnel release

MX: PO NSAIDS
PO steroids
steroid injections

P: nerves→poor healing ability→no tx if chronic

Dupuytren Contracture

PP: benign hyperplasia of palmar fascia+nodule formation→contracture

RF: white men→celtic
50+ y/o
alcohol use disorder
cirrhosis

CM: nodular/cord-like thickening
m/c→digits 4+5
tightness of digits
inability to extend fingers
tenderness

DX: clinical

TX:
NP: percutaneous needle aponeurotomy+post-op splinting
open vs partial fasciectomy+post-op splinting

MX:
fast growing nodules→steroid injections
collagenase injections

C: functional limitations
post-op recurrence more likely with surgery than mx

P: progressive dx

Trigger Finger/Stenosing Flexor Tenosynovitis

PP: nodule→flexor tendon/sheath becomes inflamed/swollen→inhibits smooth tendon gliding
-m/c→A1 pulley over the MCP joint

RF: DM
concommitant carpal tunnel syndrome

CM: painful catching/locking/snapping in digit
pain in distal palm
m/c→digits 3+4

PE: reproduction of trigger
possibly palpable nodule

DX: clinical

TX: steroid injections
tx fail→surgery

C: pt needs to release digit forcefully with other hand
finger can get locked in flexed position

Felon

PP: subcutaneous abscess of the fingertip pulp

RF: DM
nail biting

CM: localized erythema
swelling
throbbing pain

TX:
early→PO abx
severe→I&D+IV abx

Infectious Flexor Tenosynovitis

PP: severe bx infxn in flexor tendon sheath of hand/digits

RF: penetrating trauma
-2-5 days before presentation

E: m/c→staphylococcus spp

CM:
kanavel signs

• tenderness along flexor tendon sheath
  -may extend into palm/thenar space

• resting flexed position

• painful passive extension

• fusiform swelling of the affected digit

TX: IV abx+surgery consult
I+D→low threshold

C: adhesions
tendon vascular compromise+necrosis
extension into adjoining deep spaces
eventual loss of fxn of digit→entire hand

Lower Extremity Dx List

meniscus injuries

patellofemoral syndrome

plantar facsiitis

achilles tendinopathy

Meniscus Injuries

PP: menisci→act as shock absorbers within knee

E: medial vs lateral

acute→young

chronic/degerative→old+repeated microtrauma
-squatting
-twisting

CM: antalgic gait
pain/difficulty with squatting
swelling
catching
locking

PE: joint line tenderness
effusion
mcmurray
thessaly

DX: gold standard→MRI

TX:
acute tears
arthroscopic meniscus repair±debridement

more likely to get surgery:

• bucket handle

• meniscus root

degenerative tears
NP: PT
tx fail+no concurrent OA→meniscus surgery

tears more likely for surgery:

• bucket handle

• meniscus root

MX: analgesics
steroid injections
hyaluronic acid injections

C: mechanical blocks require timely evaluation

Patellofemoral Syndrome/Anterior Knee Pain/Chondromalaca/”Runner’s Knee”

PP: patella engages with femoral trochlear groove with flexion→forces on patellofemoral joint increase
-30° flexion→3x body wt
-90° flexion→5x body wt

abnormal patellar tracking→articular cartilage wear+tear
-ligamentous hyperlaxity→patella subluxes out of groove

E: strength+flexibility imbalances
altered hip/ankle biomechanics→weak quads+hip stabilizers
-running
-jumping

CM: bending→anterior knee pain
audible/palpable crepitus

PE: patellar mobility (apprehension sign)
patellar grind test
single leg squat→poor balance+pelvis drop
trendelenburg sign→excessive internal rotation of knee medially

DX: sunrise/merchant XRay→lateral deviation/tilting of patella on femoral groove
surgery→MRI→thinning articular cartilage

TX:
NP: ICE
NSAIDS
hypermobility→PT
J brace
kinesiology taping
appropriate footwear

surgery:
I: last resort
multiple subluxations/dislocations
significant soft tissue damage
-lateral release
-patellar realignment

C: must keep up with HEP

Plantar Fasciitis

PP: repetitive microtrauma+biomechanical overuse of plantar fascia

RF: recent increase in activity
pes planus/cavus
obesity
LLD
tight achilles tendon
jobs with long standing/walking

E: m/c cause of heel pain
m/c podiatry dx

CM: heel pain worse after period of rest
worst in the morning→”1st step fo the day”
localized tenderness at medial calcaneal tubercle

PE: pain with passive dorsiflexion fo great toe

DX: clinical
XRay→biomechanical etiologies/infra-calcaneal heel spur
tx fail/fascia rupture→MRI/US

TX: podiatry referral
stretching protocol
activity modifications
frozen water bottle/ice pack
padding/strapping of the arch
supportive shoes/orthotics
night splint
tx fail x 1 yr→plantar fasciotomy

MX: NSAIDS
steroid injections

Achilles Tendinopathy

PP: inflammation+degeneration+bone spurs off calcaenus→rupture of strongest+thickest tendon in body

E: young athletes→overuse
old+inactive+obese

DX: XRay
US
MRI

TX:
NP: rest
PT
severe→orthosis boot
recalcitrant→debridement/tenex procedure

MX: NSAID

Spine Dx List

herniated nucleus pulposus

spinal stenosis

spondylolisthesis

scoliosis

kyphosis

cauda equina syndrome

cervical myelopathy

thoracic outlet syndrome

Herniated Nucleus Pulposus

PP: extrusion of nucleus pulposus into spinal area
-m/c→L5-S1

RF: bending
heavy lifting
-spine in flexion

E: young→trauma
old→degernative

CM: discogenic pain
-pain at level of affected disc

radicular pain/radiculopathy
-compression of local neural structures
-lumbar radiopathy→”sciatica”

DX:
XRay

• spinal alignment

• disc space narrowing

• arthritic changes

level+morphology of disc herniation+neural involvement→MRI

TX:
NP: acute→bed rest up to x48 hrs
activity modification
PT
tx fail/intractable pain/neurologic deficits→surgical dissectomy

MX: NSAIDS
steroid packs
muscle relaxants
neuropathic agents

C: delay in tx→long-standing effects
-neurons→poor healing potential

Spinal Stenosis