MSK / Sports / Anatomy Flashcards
Treatment of bursitis, tendinitis, tendinopathy, regional MSK
Change/Avoid precipitating action
-Rest, Ice/Heat, Splinting
-PT
-NSAIDs
-IA GC
-Surgery (bursectomy, tenosynovectomy, reattach ruptured tendons)
** MC nonarticular shoulder pain **
Impingement
-Subacromial bursitis
-Bicipital tendinitis
Pathophys shoulder impingement
Superior translation of humeral head closer to coracoacromial arch during abduction due to inflamed or weak rotator cuff from overuse/strain
Shoulder impingement syndrome stages
1: <25yo - tendon hemorrahge & edema
-2: 25-40yo - tendinitis, fibrosis of subacrmoail bursa
-3: >40yo - tear of rotatorcuff or bicipital tendon
-
-*1,2 reversible
Shoulder impingement sx & XR
Pain with flexion, abduction, internal rotation actively
-Less / no pain with passive
-No inflammatory signs of swelling, redness, warmth
-X-ray shows less than 8 mm space between humeral head and acromion
Causes of impingement syndrome
Impingement syndrome= encroachment of tendons of rotator cuff
-Repetitive use with overhead work
-Rotator cuff inflammation + reflex inhib
-AC osteophytes
-Hydroxyapatite deposition
-Glenohumeral multi-directional instability
Rotator cuff tests ( and muscle tested)
-Empty Can Test ( supraspinatus)
-Resisted external rotation ( infraspinitis and teres minor)
-Liftoff test (Subscapularis)
-Subacromial impingement: Neer (supraspinatus) & Hawkins Kennedy
** Rotator cuff muscles, action, and insertion**
Supraspinatus = Abduction (from 0 to 15 degrees) and external rotation
– Top of the greater tuberosity of the humerus
-
-Infraspinatus = Abduction and ER
– Middle of the greater tuberosity of the humerus
-
-Teres minor = ER, adduction
– Bottom of the greater tuberosity of the humerus
-
-Subscapularis = IR, adduction
– Lesser tuberosity of the humerus
Impingement syndrome treatment
PT, NSAIDs, IA GC x6mo before considering surgical decompression unless full thickness tear
Physical exam findings for rotator cuff tears
Shoulder muscle atrophy
-Positive drop arm test
-“Hikes” shoulder when asked to lift the arm
Bicipital tendonitis presentation
Anterior shoulder pain worse actively (less passively)
Describe two tests for bicipital tendonitis
-+ Yergason’s (resisted supination)
-+ Speeds
** What is frozen shoulder **
Contraction of joint capsule w/ pain and reduced ROM by 50% actively and passively
-Decreased volume of joint capsule seen on arthroscopy
-
-Rarely simultaneously bilateral
-40-50% sequential bilateral
** Frozen shoulder phases , how long does it last**
1: increasing pain and stiffness x 2 to 9 months
-2: substantial stiffness but LESS PAIN x 4 to 12 months
-3: pain and function improves over 5 to 26 months.
-
-Resolves within 2 years
** Frozen shoulder RF **
DM, DLPD
-Thyroid disease,
-Paraneoplastic (ovarian Ca -shoulder/hand syndrome)
-
-Prolonged immobilization,
-Post injury (eg rotator cuff tears, proximal humerus fracture, shoulder surgery)
-Stroke, Parkinson’s,
-
-Autoimmune disease,
-Antiretroviral therapy for HIV,
-
-Genetic predisposition,
Frozen shoulder testing and most affected ROM
Significant reduction in active AND passive ROM
-ER and ABduction MOST affected
-
-Injection test: lidocaine into SA bursa. Ongoing sx = frozen shoulder (vs SA bursitis, rotator cuff)
** Three causes of nonarticular elbow pain **
Lateral epicondylitis (tennis elbow).
-Medial epicondylitis (golfer’s/bowler’s elbow).
-Olecranon bursitis.
-
-Radiculpathy
-Elbow sprain (MCL)
-Paneer’s disease - AVN of capitellum
-Nursemaid elbow (Radial head subluxation)
-Little league elbow (Medial epicondyle avulsion fracture)
Lateral epicondylitis Features
Pain with turning screwdriver, shaking hands, tennis backhand (wrist extension with elbow in full extension)
-Pain, swelling, warmth at origin of extensor carpi ulnaris, extensor carpi radialis longus and brevis, and extensor digitorum
Lateral epicondylitis DDX
Elbow arthritis,
-Loose body in the elbow joint,
-Radial nerve or posterior interosseous nerve compression
-Cervical spondylosis with radiculitis.
Medial epicondylitis Features
Pain, swelling, and warmth at the origin of flexor carpi ulnaris, flexor carpi radialis, and pronator teres
Epicondylitis Tx
Counterforce brace 10 cm distal to joint line
-Wrist splinting to prevent flexion/extension
-NSAID
-PT
-
-Surgery after 6mo conservative treatment
-
-Controversial: GC injection
Olecranon bursitis features
Limited flexion, normal extension
-Pain, swelling, warmth over extensor surface of elbow
Olecranon bursitis DDX
Trauma,
-RA, PsA, Gout/CPPD
-HD
-Infection, HIV
-DM, Alcohlism
Tendons involved with De Quervain’s stenosing tenosynovitis
Tendinitis involving the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
De Quervain’s stenosing tenosynovitis Tests
Finkelstein - thumb in fist + wrist moves ulnarly
-Wrist hyperflexion and abduction of the thumb (WHAT) test - force against thumb abduction
De Quervain’s Tx
Forearm based thumb spica splint.
-IA GC
-Surgery
What is intersection syndrome
Distal forearm pain/swelling/crepitus (6-8cm proximal to radial styloid) where APL/EPB cross over the extensor carpi radialis longus and extensor carpi radialis brevis tendons in the wrist (from repetitive wrist dorsiflexion eg rowers)
** Greater trochanteric pain syndrome (GTPS) presentation and exam maneuvers **
Pain w/ lying on side, walking, climbing stairs, rising from seated, hip ER/abduction
-1. POSITIVE Trendelenburg (pelvis tilts towards unaffected side when standing on affected leg bc of glute weakness)
-2. Single leg stand x30s = pain
-3. Tender over greater trochanter (superoposterior facet or posterior corner)
-4. Pain with resisted ABduction or external DErotation
-5. Positive FABER
** 4 causes of Trendelenburg gait **
-Neuronal injury to superior gluteal nerve,
-Gluteus medius muscle dissection during THA, glute medius abscess/tendinitis
-Developmental dysplasia
-Dislocation of the hip,
-Legg-Calve-Perthes,
-SCFE slipped capital femoral epiphysis,
-AVN
-Myositis,
-Muscular dystrophy (associated with OA),
** 2 Muscles and 1 nerve involved with Trendelenburg gait **
Gluteus minimis, Gluteus medius
-Superior gluteal nerve (L4-S1)
** Greater trochanteric pain syndrome (GTPS) causes**
Repetitive loading of gluteus medius and minimus
-Overuse (running, stairs),
-Standing on one leg
-Leg length discrepancy
-Scoliosis
-Arthritis of hip, knee or foot
-Anything causing painful foot: plantar fasciitis, Achilles tendinopathy, Morton neuroma
-Trauma
-Bed bound pressure on GTB
Greater trochanteric pain syndrome (GTPS) Tx
NSAID
-PT
-GC injection
** Reasons for refractory GTPS **
ITB tightness / Snapping hip (positive Ober or J sign - hip abduction w/ flexion)
-Leg length discrepancy → Gait abN
-Gluteus tendon rupture/tear
ITB syndrome presentation
Lateral knee pain where distal ITB goes over lateral femoral condyle
-Noble test - pressure over lateral femoral condyle while knee is extended causes pain
-Ober test
Affected Bursa and location
-Weavers bottom
-Housemaids knee
-Goosefoot
-Baker’s cyst
Weavers bottom = ischial bursitis (superficial to ischial tuberosity)
-Housemaids knee = prepatellar
-Goosefoot = pes anserine (6cm below anteromedial knee joint line; between MCL and conjoined sartorius/gracilis/semitendinosus)
-Bakers = popliteal fossa cyst/fullness
Pes anserine bursitis presentation
Knee pain lying in bed with knees opposed
-Worse w/ going UP stairs
Pes anserine bursitis RF
Obese
-Valgus
-Pes planus
Patellofemoral syndrome presentation
Anterior knee pain
-Worse with stairs
-Caused by dynamic valgus
Anterior knee pain DDX
Patellar malalignment/tracking abnormality Tendinitis quadriceps/patellae
-Tight ITB
-Meniscal pathology
-Blunt trauma, occult fracture
-Osteochondritis dissecans (patella)
-Bursitis, infrapatellar/prepatellar, Pes anserine
-Postsurgical neuroma
-Referred pain from hip
-Radicular pain from lumbosacral spine
Tests for:
–ACL injury
–Meniscus tear
ACL:
– Anterior drawer
– Lachman
– Pivot shift
-Meniscal
– Apleys
-Mcmurrays
Baker’s cyst pathophys and findings with bursitis and rupture
Communication between semimembranosus/ gastrocnemius bursa and knee joint.
-One way valve traps fluid from knee to bursa
-
-Fullness in popliteal fossa (minimal pain)
-Rupture = crescent sign (ecchymoses inferior to the medial malleolus)
Ankle sprains
MC = Low ankle sprain: Inversion involving lateral ligaments (anterior talofibular and calcaneofibular)
-High ankle = Injury to anterior tibiofibular syndesmosis