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Articular structures

synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule and juxtaarticular bone

Deep or diffuse pain
Pain on active and passive movement
Limited range of motion on active and passive movement
Swelling
Crepitation
Instability
Locking
Deformity

1

Nonarticular structures

include supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin

Painful on ACTIVE range of motion
Focal tenderness in regions adjacent to articular structures
Have physical exam findings remote from joint capsule
Rare to have swelling, crepitus, instability, deformity

2

Osteoarthritis

*Most common MSK condition*

Crepitus with active motion: crunchy

Risk factors:
-age
-obesity
-female gender
-joint injury
-genetics

*Knee, hip, wrist (carpometacarpal squaring), hand carpometacarpal, DIP, PIP *(no synovitis, erythema, warmth), *only RA involves the MCP*), spine, shoulder (NFL touchdown sign is positive

Chronic pain, loss of function
*-Morning stiffness < 30 min*

Diagnose with history and physical

Xray: insensitive test, absence of findings does not rule out disease
*-asymmetric joint space narrowing*
-spur formation
-cortical bone thickening
-subchondral cysts

ACR criteria:
-cold effusion

3

Pes Anserine Bursitis

Pain just below knee at ateromedial aspect of tibia that occurs when exercising or climbing

4

Meniscal injury

Pain usually occurs acutely and is associated with trauma

Buckling and locking of knee

Tenderness over joint line

McMurray: clicking felt when knee compressed and rotated during varus and valgus; point knee towards shoulders while flexing

5

Trochanteric bursitis

Pain and tenderness over greater trochanter

Pain can radiate down thigh in some cases

Should do Xray to insure no other contributions

6

Biceps tendonitis

results from impingement or instability

Pain aggravated by lifting, pulling or repetitive overhead movements

Tenderness on palpation of biceps tendon with arm slightly externally rotated

7

Adhesive capsulitis

ROM limited on active and passive motion

Usually painless

Present with patient with chronic shoulder problems, seen in Parkinson's patients

Physically cannot raise arm
-should be able to get arm to T7-T8

8

Rotator Cuff Tendonitis

Pain is worsened activity and night

*Most common shoulder pain: 29%*

Usually no history of trauma

Should not have weakness (if weakness = tear)

9

Carpal Tunnel Syndrome

Nocturnal aching wrist
-pain with squaring of the palm
-bilateral hand numbness and tingling: *helps with shaking it out
-worse at night
-numbness along middle finger*

Risk:
-female
-obesity
-pregnancy

Tinel's = taping test
Phalen's = funny; 1 min; fingers pointed down, wrists facing each other

10

DeQuervain's Tenosynovitis

Exercise related involving extensive wrist and thumb action
-gripping/grasping like carry small children

Tenderness at anatomic snuff box

Finkelsteins maneuver to aid diagnosis

Women 30-50 yo

11

Rheumatoid arthritis

Need to check RF, anti-ccp, Xrays (periarticular osteopenia, erosion, *symmetric joint space narrowing*)

*Involves the MCP and PIP joints bilaterally*

*Symmetric polyarthritis with prolonged morning stiffness*

30% have normal labs

12

Psoriatic arthritis

*Dactylitis: finger like a sausage

Pencil in cup deformity on Xray*

Nail pitting is specific

Can precede skin findings by up to 10 years

13

Spondyloarthropathies

refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself

14

Acral lentiginous melanoma

with nail bed involvement the nail plate may have dark brown discoloration (due to melanin).

15

Beau's lines

transverse grooved (e.g. depressed) lines parallel to lunula occurring after serious *medical illness, post-surgical and/or severe infections*.

16

Clubbing

produced by soft tissue growth at the nail bed and identified by noting a greater anterior-posterior distance at the nail bed as compared to the same distance at the distal interphalangeal joint (also creates a nail-finger angle >180 degrees).

typically occurs in response to *thoracic disease, including cyanotic congenital heart disease, cystic fibrosis, pulmonary fibrosis, lung cancer, and severe hepatic cirrhosis* (with hepato-pulmonary syndrome). Although reported in severe *COPD, other pathology (e.g. lung cancer)* must be excluded before accepting COPD as the sole cause.

17

Koilonychia

(aka spooning of nail) - the nail curves upward away from nail bed (concave instead of the normal convex appearance). This is a classic finding in *iron deficiency anemia/malnutrition.*

18

Lindsay's nails

also termed half-and-half nails, the proximal portion of the nail is pale/whitish while the distal 20-60% of the nail is brown, pink or reddish.

*Associated with renal failure and hyperkalemia (abnormal heart rhythms, peaked T waves with QRS widening*
-administer calcium

19

Mees' lines

transverse white band parallel to the lunula.

Originally described with arsenic intoxication, may also be seen with thallium as well as after acute medical conditions such as lymphoma and malaria.

Most common etiology is following *cancer chemotherapy (a poison of sorts) and arsenic poisoning*

20

Muehrcke's lines

two or more paired transverse white bands associated with severe *hypoalbuminemia* (usually < 2.2 g/dL).

21

Nail pitting

small depressions in nail that are present in up to 50% of patients with *psoriasis* (usually more severe cases).

22

Onycholysis

irregular separation of the nail plate from the hyponychium. Can be traumatic in origin, but also seen in *psoriasis and hyperthyroidism/Graves's*

23

Periungual fibroma

(aka Koenen tumor) - flesh-colored papule of nail folds (toes > hands) seen in ~50% of patients with tuberous sclerosis (see below under skin).

24

Quitter's nail

heavy cigarette smoking leads to orange-brown discoloring of the nails and fingers holding the cigarette. A normal proximal nail with distal discoloration indicates smoking cessation - chronicity of abstinence can be estimated by understanding that nail growth is 0.8 - 1.0 mm per week.

25

Splinter hemorrhages

small brown or red streaks perpendicular to the lunula, and often involving the distal nail. These are most commonly traumatic in origin, but classically a consequence of *microembolism from infectious endocarditis*. They are also reported in scleroderma and trichinosis.

26

Terry's nails

proximal paleness of nail with only 1-2 mm of preserved pink distal border (appears dark).

-originally described with *liver cirrhosis, TB, heart failure,* but can also be seen in other severe medical conditions (e.g. heart failure, poorly controlled diabetes, hepatitis).

27

Arachnodactyly (aka spider fingers)

long fingers that are associated with Marfan syndrome. The wrist circumference is less than the distance encompassed by the subject's 5th finger and thumb.

28

Bouchard's node

bony protuberance of proximal IP joint without findings of inflammation - this is a finding in osteoarthritis.

29

Boutonniere deformity

produced by extension at the distal IP joint and flexion at the proximal IP joint - *a finding in severe, chronic rheumatoid arthritis*.