MSK Conditions Clinical Integration

Condition Description Pathophysiology Clinical Presentation & Findings Management and

Prognosis or Notes
Cervical Spine
Bones
Dens (C2; axis)
Fracture
Most common
upper spine
fracture, car
accidents, falls
Occurs at base of dens
post. displacement of dens
toward spinal cord
X-ray/CT cord injury in 15%
cases; blood supply iffy
so delayed healing/non-
union
Hyperflexion
Teardrop Fracture
Triangle shape
frag avulsed;
Severe flexion
force (head on car
crash)
Ant. longitudinal lig pulls on
anterior vert. body; avlusion
frag attached to lig. Rest of
vert. body is distracted
posteriorly
water drop on CR
C5 body post.
displaced
tear drop attached
to lig
subluxed facets
compress
cordneuro
injury

Most serious cervical
spine injury. unstable Fx
w/ little chance of
neurological
improvement
Extension Teardrop
Fracture
Ppl fall and hit
face; C2 or C3
common
sudden hyperextension,
ant. longitudinal lig
avulses bone frag from
anterior inferior margin

Fx often stable and NOT
result in cord injury
Vertebral Axial Load
Burst
Vert. body
compressed both
anteriorly and
posteriorly.
From traumatic injury vert.
body explodes from high-
energy axial load; falls from
heights
Pieces of vertebra can
displace into surrounding
tissues and spinal cord
Often injures cord of
cauda equine

Jefferson Axial Load
Burst
See above

Direct blow to top of
headfx ant. and post.
arches of C1 (atlas)
Can see breaks
between the lateral
masses and the
arches; CT
InjuryC1 expandsso
uncommon to injure
cord
Joints
Cervical
Degenerative Disk
Disease (OA)
Normal aging
process, disk loses
flexibility and
shock absorbing
func; start age 25

Nucleus pulposus loses
[proteoglycans] that bind
waterdehydrates. Also
[Collagen] in ECMbecome
white and firm.
height diskchange
vertebrae alignment
pressure on Vetebral
endplates get sclerosed,
form osteophytes. (in
attempt to grow extra bone)
Progress to tears in annulus
fibrosis.
Misalignmentsublux
facet joints; not supported,
get OA at facet joints;
progressive cycle
Eventual neck pain assoc. w pathology
Loss normal cervical lordosis bc
paraspinal muscle spasm in response to
pain
ROM: normal to limited
local tenderness over paraspinal muscles
and over cervical vertebra; otherwise
pain not reproducible w palpation

CR: narrowed disk
spaces, osteophytes,
bone sclerosis

NSAIDs, opioids severe
Strengthen paraspinal
muscles for support,
stretching
If severe, surgical
cervical spinal fusion

PROG: progressive w/
age and additional
trauma
Cervical Disk
Herniation
Normal aging as
disc degenerates

Microtears in annulus
fibrosis inflammation in
surrounding tissue and
nucleus pulposus
protrudes from tear.
Typically posterolateral
pathway bc flexion of spine
creates ant. compression,
pushing pulposus posterior
-can compress nerve roots
(cervical radiculopathy)
OR directly compress
spinal cord (cervical
myelopathy)
Inflamm alone may affect
nerve roots
-local neck pain midline or in cervical
paraspinal muscles; worse w movement
-if radiculopathy, sharp shooting, tingling,
numbness, aching, heaviness sensation
radiation to shoulder and/or upper
extremity, eventual muscle atrophy in
myotomal pattern
-if myelopathy,
weakness,muscle tone,
spasticity in legs,
hyperreflexia lower limb
-Cervical muscle spasms and
loss of normal lordosis
-abnormal gait bc of
weakness/spasticity in legs
-ROM limited bc of pain
-Spurlings Test + for nerve
root compression ,
MRI /CT confirms diagnosis
-NSAIDS, opioids; muscle
relaxants
-Epidural Corticosteroid
injection pain relief
-relaxation and ROM
exercises, postural
training,
-traction for temp relief
of compression
-Ice/Heat compress to
alleviate muscle
spasm/pain

PROG: most resolve
w/in 6 wks. More
complicated if
radiculopathy or
myelopathy
Muscles/Tendons
Cervical Muscle
Strain
Injury of muscle
from incorrect
exertion or
overuse. Most
common reason
for neck
pain/headaches
Tension in post. Cervical
parapsinal muscles which
compress greater occipital
nerve (C2 dorsal rami)

- Acute onset sharp/aching/throbbing
pain localized to posterior neck, worse w
movement; pain can migrate to
headheadaches
-loss of cervical lordosis bc muscle spasm
-ROM: limited bc of pain/stiffness
-reproducible pain w palpation of muscle
-no CR unless trauma

-NSAIDs
-Ice during acute painful
period (1st few days),
-Neck bracing temporary
(1-2days) to rest
muscle ,
-Superficial/deep heat
(days to weeks after
injury)
Stretching
PROG: most recover
shortly

Whiplash Syndrome Usually from a car
accident caused by
sudden force
Rapid and extreme ROM
btwn hyperflexion/
hyperextension injures
facet joints, ligaments,
muscles
-Deep aching, sharp, throbbing neck pain,
from base of skull to cervicothoracic junc
of spine ; worse w movement
-potential pain in trapezius, SCM, or
headaches
- paraspinal muscle spasmloss lordosis;
tender muscles; tender along spinous
process
- ROM: limited bc pain,
-CR in flexion/ext to rule out vertebral
fractures and spinal instability
-NSAIDs, opioids, muscle
relaxants
-ACUTELY: Cervical
collar, ice massage

PROG: 80% full recover
3 mo, 20% have
continued pain bc
chronic muscle spasm or
ligamentous instability
Ligaments
Atlantoaxial
Instability
High risk pts:
Down syndrome
(congenital laxity),
RA (structural
damage); or
trauma in general

mobility of atlantoaxial
joint btwn anterior arch C1
(atlas) and dens C2 (axis)
-abnormalities of
transverse ligament; dens
moves
posteriorly
and may
compress
cord
(myelopat
hy)
Many asymptomatic.
Symptoms w/ subluxation of
denscompress cordneuro problems:
weakness/sensory impairment in
arms/legs, tone, hyperreflexia,
abnormal sensation
sudden cord compression => death
ROM: limited to pain,
Midline deep pain bc of paraspinals
spasm
-CR predental space, normal 3mm;
distance posterior surface ant. arch C1
-NSAIDs, opioids
-Surgical fixation
-detect early in high risk
ppland avoid neck
manipulations or high
impact exercises

PROG: fine if treated w/
surgical fixation but bad
if not and can cause
death
and anterior surface dens (C2)
Nerves/Vessels
Cervical
Radiculopathy (see
chart of dermatomes
at end)
-C6 and C7 most
common
-dermotome
sensory changes;
radiate shoulder
and upper
extremity

Root compression in spinal
canal or neural foramen
from:
1) herniated disc or
osteophytes
2) inflammation in soft
tissues surrounding; most
commonly from tears
annulus fibrosisrelease
cytokinessinuvertebral
nerve contain sensory
nerves (nociceptive) to
these tissues (post. long lig,
ligamentum flavun,
peripheral fibers annulus
fibrosis, VSM, dura mater,
periosteum of spinal canal
-parasthesia (numbness, tingling,
prickling) in dermatome pattern of root
-motor deficit if affect ventral motor
root fibers also
-cervical parapsinal muscle spasm,
ROM limited as extension
compressionpain
-local tenderness over paraspinals
from spasm but palpation in extremity
should NOT reproduce pain
-Spurlings
-EMG: assess degree damage
-CR may help w cause compression or
MRI
-NSAIDS for
inflammation,
antidepressants, anti-
seizure meds for
neuropathic
-Cervical traction,
stretching,
-epidural corticosteriod,
-surgerical excision of
herniated disk,
osteophytes

PROG: fair most
improve w/
conservative treatment
Cervical Spine
Stenosis
Narrowing of the
cervical spinal
canal

-disk herniation, osteophyte
on vertebral end plates,
hematoma after trauma,
tumor, foreign body
-if significant
narrowingcan get
compression of roots
(radiculopathy) or of cord
(myelopathy)
Neck pain, gradual onset of pain wks to
months, and neck stiffness, tenderness
over cervical paraspinal muscles and
midline
-Cervical muscle spasms, loss of lordosis,
-if cord compressed, abnormal gait or
bowel/bladder incontinence
ROM limited bc pain , neck extension
painful- avoid as compression
-Spurlings: + implied radiculopathy
-EMG: degree involvement
-Sensory/motor reflex testing
---if radiculopathy: sensory abnormal,
upper extremity weakness, reduced
reflexes
----if myelopathy: muscle tone, reflexes
(patella/Achilles) and sensory abnormal
MRIcanal size, etiology, cord compress
-NSAIDs, opioids, oral
corticosteroid for acute
pain/weakness
-corticosteroid injection,
-excision of
osteophytes/ herniated
disk
PROG: herniation good ,
on its own, others, need
treatment or surgey
(remove tumor or
foreign body) (aimed to
prevent progression, not
reverse deficits)

Lumbar Spine
Bones
Spinal Compression
Fx-Osteoporosis
Typically at
thoracic level and
thoracolumbar
junc
Vert. body compression
fxcollapsing crushing of
boneheight vert body

At risk: osteoporotic/post-menopausal
women, elderly men, long-term steroid
med users, young person from trauma
Sudden pain in young person
Older pt w osteoporosis may have vague
pain, but might not notice
Avoid corticosteroids in compression fx;
bc they weaken bones/ligs

Spinal Compression-
Traumatic
See above See above Often due to fall from height land on
buttocks or feet. collapsed the area
pain
Normal T10
Compression fx T11

Spondylolysis

5% pop, more
common athletes:
gymnasts, football
linemen who
hyperextend of
spine.

Fx of pars interarticularis
(btwn superior and inferior
articular processes of vert.)
usually L5/S1
If bilateral break can have
listhesis too

-Scotty Dog neck collar break on CR
- low back pain , over L5 usually
-hamstring tightness, limited forward
bending
-Antalgic gait (abnormal as result of
pain), reactive muscle spasm
-ROM: limited spine extension bc of pain

NSAIDS, muscle
relaxants
-surgical fusion in
extreme
-stretching of back/legs
-posture correction
-lifting techs, strengthen
core muscles (back/abs)

PROG: w/o
spondylolisthesis;
usually good w/
conservative treatment
Spondylolisthesis

NOTE: spondylosis:
refers to any
conditions of spine
Slipping caused
by spondylolysis
in young ppl OR
OA in old ppl
Vertebral body slippage
fwd onto vert body below
from broken pars
OR in degenerative disk
disease: disk
Stable: slippage unchanged in flexed or
extended position;
Unstable: slippage degree changes when
flexed compared to extended; ex.
Sheering force involved if changes when
PROG: w severe,
unstable
spondylolisthesis
NEED surgery
heightlaxity in supporting
ligsallows vertebral
slippling. Stable or unstable
sit to stand position
-Rest see above

Joints
Lumbar
Degenerative Disk
Disease (OA)
See Cervical OA
Red arrow: disk
space narrowing
Blue arrow:
sclerosis and
ostephyte adjacent
to disk space
Green: sclerosis
Orange:
osteophytes from
narrowed facet
joint spaces

-see Cervical OA

-pain midline, worse w/ movement,
weight bearing activity and back
extension once facet joints involved
-loss of lordosis from paraspinal muscle
spasm,
ROM: normal to limited,
-local tenderness over paraspinals from
spasm
-pain from OA is NOT reproducible by
direct palpation
-CR narrowed intervertebral disk space,
sclerosis/osteophytes
-MRI desiccated disk
-NSAIDs, opioids
-Weight loss
-gentle ROM exercises
-posture/lifting techs
-strengthen paraspinals
and ab muscles
-if severe, stiffness +
extreme pain, surgical
fusion
PROG: poor, will
progress w/ age and
additional trauma
Lumbar Disk
Herniation


Tears in annulus fibrosis
1) inflammatory response
affecting adjacent tissues
2) nucleus pulposus
protrusion;
Typically posterolateral
pathway
(post. long. Lig
thinner) so
disk herniates
around it

NOTE: in lumbar L3/4
herniation, affects L4 nerve;
L3 manages to come out
-local low back pain midline or lumbar
paraspinals, worse w/ low back moving
-if lumbar radiculopathyradiating pain
to butt/lower extremity; abnormal gait
-if compress thecal sac, (cauda equine
syndrome) bowel/bladder
incontinence, weakness, muscle tone,
loss of normal sensation /reflexes in legs
bc affect lower motor neurons (vs
cervical herniation which affected upper
motor neurons and saw muscle tone in
lower extremities)
-Bilateral muscle spasms, loss lordosis
ROM limited bc pain, muscle atrophy,
-Spurlings maybe + if nerve root
-NSAIDs, opioids, muscle
relaxants
-Corticosteroid injection
in epidural space
-relaxation ROM
exercises,
-postural training,
traction, Ice/heat for
muscle,

PROG: most resolve
w/in 6 wks; more
complicated in neuro
involved
above herniation compressed
-MRI/CT to confirm dx
Sacroiliac Joint
Dysfunction

Change in
alignment of SI
joint;
Anterior sacroiliac
lig; posterior
sacroiliac lig;
sacrotuberous lig;
sacrospinous lig
s in SI ligaments that
normally provide stability
can shorten/tighten from
sedentary, can get lax
during pregnancy from
hormones, can get uneven
joint surfaces and fuse bc of
degenerative aging s ,
stress from imbalance of
surrounding musculature
-gradual low back/buttocks deep
aching pain, progressive w/ hip
movement, , can radiate to
anterior/posterior thigh
pain w/ hip flexion, abduction, external
rotation on same side walking, standing,
and weight bearing
-Reproducible w/ palpation over SI
ligs near PSIS
-Leg length test, FABER test
-CR usually normal
NSAIDs, ice in acute,
deep heat/US in chronic,
gluteal/paraspinal
muscle strengthening
-Corticosteroid injection
PROG: good: self
limiting usually, need
early treatment
Fair to poor: if
misdiagnosed/treatment
delayedchronic,
debilitating conditon
Scoliosis Lateral curvature
of spine. Usually
thoracic and
lumbar regions
Girls 7x>boys

Rotation of vertebrae, single
C curve or double S
Convex to right: dextro-
Convex to left: levo-
Idiopathic in kids
Adults: 2 to spondylolysis/-
listhesis, OA, stenosis,
compression fx due to
osteoporosis
Kids: Curvature usually not noticeable
until > 20, usually no symptoms
Adult: pain localized to reg. of deformity
-Asymmetry of spine when pt bends fwd,
Rib cage/scapula higher one side,
asymmetric waist line
ROM normal,
local muscle tenderness in curvature area
from spasm
CR to confirm degree of curvature
<10 no treatment
20-30 monitor,
brace (prevents further,
wont correct)
>40 or if breathing
difficultysurgical fix
PROG: progressive until
puberty then stabilizes.
Adults: progresses w/
degeneration
Ankylosing
Spondylitis

Ankylosing (joint
fusion) spondylitis
(spinal
inflammation)
Chronic seronneg.
Spondylo-
arthropathy w/
axial involvement
(SI and spine),
Class I HLA-B27
strong association
More men,
Begin young adult, in SI
joints (sacroilitis). Pannus
forms, erodes
fibrocartilagentous
jointossification and bony
fusion (ankylosis)
-Progressive stiffening of
spine w/ fusion.
Enthesitis (inflamm tendon
and lig insertions into bone)
-low back pain, worse w/ rest but pain
w/ activity (NOTE: opposite of OA);
morning stiffness ~30min
-enthesitis: accounts for pain, stiffness,
and restriction at SI and spinal joints;
also at Achilles tendon and plantar fascia
-No lab test diagnostic for AS
+ HLA-B27 useful but NOT dx bc many +,
not all get AS
-CR EARLY: SI normal MIDDLE: SI joints
widened END: sheets of ossification
obscure joint
NSAIDS,
Early dx to relieve back
stiffness, good posture,
ROM
PROG: mild to severe
cant predict the disease
progression
typically 20-30YO

-Bamboo spine squaring of vert body
and fusion of adjacent levels, calcification
of spinal ligs

Muscles/Tendons
Lumbar Muscle
Strain
Incorrect exertion
or overuse. Most
common reason
for low back pain.

Correlated w stress, tension,
continual awk back
positions.
Acute onset sharp, aching, throbbing
pain, localized to posterior back and
buttock, worse w/ back movements, can
migrate.
-muscle spasm loss of normal lumbar
lordosis, ROM limited to pain/stiffness,
pain reproducible to palpation of
affected back muscle.
No CR unless trauma
NSAIDs, Ice acute, temp
back bracing 1-2 days to
help rest msucles; do
NOT brace >2-3days bc
atrophy and
deconditioning
Chronic/subacute: deep
heat; stretching
PROG: most recover
spontaneously w/in
days to weeks
Nerves/Vessels
Lumbar
Radiculopathy


SEE dermatome/
myotome patterns
at end
Compression or
injury to spinal
nerve roots
L5/S1 most
common

NOTE: if L4/L5
level, if impinge at
foramenaffect
L4; if impinge in
cordaffect L5
which exits below
Osteophyts or herniated
disk compressing in nerve
roots in canal or neural
foramen.
Tend to radiate to gluteal
and lower extremity. See
cervical radiculopathy
Sinuvertebral nerves have
nociceptive fibers
producing the pain signal
from inflammation
Paresthesia (neuopathic) in dermatomal
pattern; potential muscle weakness if
ventral roots affected
Painful antalgic gait, muscle spasm
lumbar paraspinals. ROM limited as
extension compression.
Local palpation in extremity NO
reproduce pain. Local tender over
paraspinals though
-Straight leg test, EMG assess
-can produce Sciatica symptoms, but
radiculopathy not only cause sciatica
CR rule out cuase. MRI better
NSAIDs for inflamm,
antidepressants, anti-
seizures for neuropathic
pain
-proper posture, lifting
techs, lumbar traction,
stretch muscle spasm,
improve paraspinals and
abs. Muscles for stability
Epidural for pain relief,
excision of herniated
disk.
PROG: fair; conservative
treatment
Lumbar Spinal Narrowing of See Cervical Spinal -gradual onset of back pain and stiffness -NSAIDs, opioids, oral
Stenosis lumbar spinal
canal.
Stenosis. Various causes
can result in compression
root (radiculopathy) or
cauda equine (cauda
equine syndrome)

lower extremity wkness, sensory
abnormal, bowel/bladder incontinence
(cauda equina)
suspect stenosis if bilateral radiculapthy
w or w/o bowel/bladder symptoms
walk w/ fwd flex (stooped) position-
opens canal and relieve some symptom
-Oppositie of cervical stenosis: here have
muscle tone and reflexes in lower
extremities
-loss lordosis, ROM limited to pain, esp
back extension bc canal size, tender
over paraspinals/midline from 2 spasm
Straight leg test + if radiculopathy
Sensory/motor/reflex testing is KEY to
assessing neuro involvement, MRI
corticosteroids
-epidural corticosteroids
-if severe
decompression
surgery/excision to
prevent further
compression/damage
-myeloradiculopathy:
herniated disk cause
both radiculopathy and
cord compression
-Upper Motor Neuron
spasticity, Babinski
sign present w/ spinal
cord compression
need to treat!
Shoulder Region
Bones-Fractures
Humerus Surgical
Neck Fracture
Most common
proximal humerus
fracture. Old ppl
w/ osteoporosis at
risk.
Falling on outstretch hand
or direct impact to shoulder.
Axillary nerve most
commonly injured
. Sensory s over deltold muscle and
weakness w/ abduction of shoulder
joint (bc axillary nerve innervates delt)
-EMG (electromyogram) and NCS to
diagnose nerve damage
-CR for fracture

Humerus Midshaft
Fracture-Pathologic
Weakened bone
from pathologic
lesion
Trivial pressure causes
fracture. Benign/malig
neoplasms, osteomyelitis,
pagets. Risk injury to
Radial nerve
-if radial nerve injured, lose sensation
over dorsum of hand and weakness w/
wrist extension.
-EMG and NCS to det. Nerve damage
-CR for fracture

Clavicle Fracture Most common
childhood fracture
(incomplete
ossification til
teens)
Direct force applied to
lateral aspect of shoulder
fall onto outstretched hands
or car accident.
80% mid-clav, medial to coracoclavicular
lig; proximal frag typically displaced
upward bc of pull of SCM muscle.
-CR for fracture
Joints
Shoulder instability
and Dislocation
Anterior
dislocations most
common. Football
and volleyball
players; Shoulder
joint depends on
depth glenoid
cavity from
labrum, joint
capsule, capsular
lig, and rot cuff to
stabilize bc only
1/3 humerus head
on glenoid
Ligament laxity shoulder
subluxation (partial
instability) or dislocation,
Direct force of repeated
activity causing abduction
and external
rotation of
shoulder joint.
Inferior
glenohumeral
lig most commonly gets
laxant. Dislocation.
Posterior disloc acute
trauma to anterior shoulder
(football lineman)
posterior force

-asymptomatic till injury
-overworking of rotator cuff/shoulder
muscles trying to stabilize joint chronic
muscle spasm, diffuse aching pain
-if actual dislocatesevere sharp pain
w/ move
-shoulder exam normal, but local
tenderness (traps, rhomboids, rotator
cuff)
-Obv asymmetry/deformity, ROM very
limited both passive and active
-CR to see position of humeral head, but
often normal in pts w/ shoulder
instability w/o dislocation
-positive sulcus sign
-NSAIDs, if severe
Opioids
-Joint reduction/relocate
to avoid neuro/vascular
injuries,
-strength training for
surrounding muscles,
avoid shoulder
abduction/ext (tennis/
volleyball serve,
throwing)
--after one disloc.more
prone to another
(Apprehension test:
abduct, bent elb, passive
ext. rot; pt hesitates)
Prog: good if no neuro
defects and labrum
intact; if notrepeat
dislocate possiblw
AC Joint injuries
(acromioclavicular)
Fall or blow to top
of shoulder
Acromion driven to ground
AC sprain CC ligs ok, but
injury to AC ligs (grade I)
AC separation both AC and
CC ligs injured partial sep
(grade II) of
clavicle from
acromion. If
complete
separation
(grade III)
Sprain swelling, tenderness, some loss
shoulder movement (esp aDduction)
AC separation severe pain esp w/ move
-asymmetry of shoulders, bump/high
riding tip of clavicle in AC joint
separation
-painful to touch AC joint, limited ROM
-CR for pos of acromion and clav,
distance of AC joint space. Can take CR w
downward traction of arm w weights to
show dist.
-NSAIDs, opioids
-rest and arm sling for
sprain, maybe surgery
for separation
Prog: normal joint fxn 6-
8wks w/ cons. treat,
might have residual
bony callus over AC joint
(think
lori)
Adhesive Capsulitis Frozen shoulder.
40-70YO, 3% pop.
males less affected
than females; wide
spectrum of
limited
ROMcapsule has
tightened up;
compare to other
side to eval
Chronic immobility,
scarring, thickening of joint
capsule, progressive loss
ROM. 2 types:
1) No prior shoulder
condition but stroke,
muscle weakness, brain
injurylimited movement
2) prior injury shoulder
impingement, OA, surgery
-deep dull aching pain and stiffness of
shoulder joint. Onset gradual and w/
shoulder move. Difficulty sleeping on
affected side
-shoulder looks normal/symmetric
-ROM decreased actively and passively.
External rotation first to be affected.
-diffuse tenderness over ant/post capsule
-CR usually normal, but rule out other dx
-MRI can show scarring capsule, but not
needed for dx
NSAIDs
PT stretching program,
US heat, ROM exercises
-Glenohumeral joint
injection w/ lidocaine
and corticosteroid
Prog: good w/ early
intervention.
Prevention is key!
Dont prolong
immobilization
Muscles/Tendons
Shoulder
Impingement
Syndrome
AKA
-rotator cuff
tendonitis
-supraspinatus
tendonitis
-subacromial
Bursitis,
-calcific bursitis
-tendonitis
Degen. process of shoulder
from overuse or previous
injury. Ischemia to Rot Cuff
tendonsmicrotears,
initates inflamm response
to repairvascularization
(granulation tissue) and
deposit Ca++
crystalscalcification
collects under subacromial
bursalead to more
inflamm (calcific tendoinits
or bursitis) eventually
leads to full rotcuff
tearmore
inflamecytokines can
erode bonedamage
Gradual onset of ant/lat shoulder pain
hurts when reach overhead
-night pain, cant sleep on affected side
-Shoulder looks normal, unless can see
atrophy in supraspinatus, ROM limited in
aBduction and flexion
>90 deg, pain w Int rot
w/ arm abducted
(Hawkins) or flexed
(neers)
-tender over point of
shoulder & laterally near
subacr. Burs
+ Hawkins sign, + Neers sign
CR- can see complete tear, not partial; see
joint space narrowing; sclerosis
US-if operator good, can see tear
MRI-show tear
NSAIDs, opioids
-in acute stagesice to
ant/lat shoulder,
-in chronic deep heat
-dont reach overhead,
no flex or aBduct >90
-passive ROM needed to
prevent adhesive
capsulitis,
Corticosteroid
injectsubacro. bursa
Surgical excision of part
of acromion to prevent
compression of
supraspinatus tendon
Prog: most resolve w/
conservative treat.
Nerves/Vessels:
Peripheral
Nephrapthies
NOTE: paresthesia: skin sensation, such as
burning, prickling, itching, or tingling, with no
apparent physical cause


Thoracic Outlet
Syndrome

Compression of
lower trunk of
brachial plexus or
subclavian vessels
Dev. Anomalies cervical
rib/long transverse process
C7, posttraumatic fibrosis of
scalenes, women 20-50
Pain and paresthesia along ulnar aspect
of forearm, and medial 2 fingers.
-IF vascular compression intermittent
swelling & discoloration of arm that
Home exercise program
that promotes muscle
strengthening and
correct posture
as they course
btwn clavicle and
1
st
rib.
most common worsens when arm is raised over head.
Brachial Plexopathy Nerve traction
injury to shoulder.
Weakness and
sensory loss
depend on degree
and location
injury.

Most COMMON: brachial
plexus upper
trunktraction force to C5-
C6 roots when shoulder
forcibly depressed while
head/neck tilted opposite
side. In children C5-C6
Erbs palsy-baby when
giving birth
Burners/Stingers
transient injuries C5-C6 root
Klumpkes palsylower
trunk injury; traction force
(C8-T1) when falling from
height (grabbing ledge)
Erbs arm hangs useless at side
from shoulder girdle/biceps
paralysis. Also loss sensation at
wrist Waiters tip deformity;
not really a deformity of the
hand
College athletes, football
players

Claw hand-intrinsic
muscles of hand affected
(lumbricals and
interossei), so finger
flexors (FDS and FDP) are
unopposed.; 4
th
and 5
th
digit




Poorer prognosis

Suprascapular
Nerve Entrapment
Purse neuropathy
pressing against
upper scapula
Suprascapular nerve from
upper trunk brachial
plexuscourses across
post. Trianglebeneath
suprascap. Lig and if
pressure on lig, then nerve
gets entrapped
Sensory fibers post aspec of shoulder
joint => dull shoulder pain when nerve
entrapped. No neck pain, maybe some
shoulder movement weakness

Radial Nerve
Entrapment-Upper
arm
Radial
nerveterm.
branch of post.
cord
- Crutches at the
armpit/axilla
-compression in radial
groove deep to triceps , Sat.
night palsy (ex. Arm over
back of chair entrap along
post. Humerus)
--@axillaElbow ext. (triceps) weakness,
sensory abnormal in posterior
arm/forearm
-@radial groovesensory s on radial
side of forearm, wrist, and dorsum of
lateral 3.5 fingers (not tips) Motor: cant
extend wrist, thumb, and fingers so hand
droops. Wrist drop

Elbow, Wrist, Hand
Bones-
Fractures/Dislocate

Supracondylar
Fracture
Distal humerus
proximal to
Fall on out-stretched hand
w/ elbow joint in
damage median, radial, and ulnar nerve.
Compartment syndrome in volar forearm
If malreduction, elbow
can get deformed and
epicondyles;
common and
serious in
childrenhigh
risk neurovascular
problems
hyperextension

w/ brachial artery => muscle necrosis
from ischemia; can lose forearm; pain
Volkmanns ischemic contractures bc
muscle shorten and pulls on tendon
(permanent flexion -> claw like
deformity; more flexor muscles)
deviate medially called
cubitus varus
(abnormal carrying
angle)
Ulnar Shaft fracture Policeman beating
you up with his
nightstick
Forearm struck by object
Nightstick fracture or
parry
Also falls/car accidents
Transverse, non-displaced

Radial head
dislocation
(Monteggia fracture-
dislocation)
Fall on
outstretched hand
w/ forearm in
excessive
pronation
Fracture to prox 1/3 of ulna
w/ anterior dislocation of
radial head w/in proximal
radioulnar joint.
Must include elbow in CR otherwise can be
missed.


Radial head fracture Trauma, fall on outstretched
arms
Radial head pressed into capitulum of
humerus
May see displaced posterior fat pad in
traumahigh prob of fracture

Greenstick fracture
(like see w green
sapling)
Incomplete
fracture in kids
Quick twisting motion w/
axial compression (fall
backwards on outstretched
hands)
Cortex of bone
on one side
bends while
other side
fractures
Have to break the other
side so that healing takes
place properly.
Torus fracture of
radius (buckle
fracture)
Common in kids;
rare in adults
Bones are pliable in kids, so
bone bends under
stressraised buckle w/o
fracturing other side
Distal radius common site, can see a
little nub on CR sticking out of radius; but
any long bone possible

Colles fracture Most freq broken
bone in upper
extremity
Commonly
adults>50YO
Fracture of distal radius.
Break a fall on outstretched
hands or forced dorsiflexion
Posterior displacement, angulation, and
rotation distal frag; >50% pts also have
fracture ulnar styloid process.
Wrist pain, local tenderness, swelling
x-ray dx;
NSAIDS, splint if fracture
in good alignment or
must reduce w
internal/external
fixation and cast
Confused w
scaphoid fract

Scaphoid fracture Most freq fractured
carpal bone. More
common young
adult athlete

Break fall by landing on
palm of handforces wrist
into ext and radial deviation
(abduction)force
transmitted to arm via
scaphoid bone
If swollen, tenderness base
thumb, and no colles
fxthink
scaphoidsplint/protect
-Easy to miss bc no bruising & ppl think
sprained wrist; pain radial side wrist
-scaphoid bone forms floor of snuff box
and fracturetenderness in area
--delayed healing or non-union is
BADavascular necrosis proximal frag
bc blood supply normally trickles from
distal half and lose w fxwrist strength
x-ray may be normal; CT or MRI may
show w/in 48-72hrs
Commonly missed, fx may not show up
for 10days
NSAIDs, Thumb spica
cast, surgical fixation if
dislocate and healing
poorly.

Metacarpal #5
Angulated Neck
fracture
Boxers fracture Head of 5
th
metacarpal
breaks and moves toward
the palm forcing MCP of
little finger into
hyperextension (bc MCP
joint is volarly displaced)
and collateral ligaments get
slack


Phalanx Growth
plate fracture
Salter Harris
fracture of
phalanx; 5
possible Grades, V
most serious
Typically from actue or
overuse (gymnast/pitcher)
or physical abuse

Always exam child
complaining of pain;
Dont have work through
pain
Distal phalanx
fracture
Sports injuries Intra-articular fracture of
distal phalanx associated w/
extensor tendon injury
(dorsal) or flexor tendon
injury (volar)
forced flexion of DIPtension on
extensor tendonavulsion of dorsal
proximal margin of distal phalanx

Joints
Nursemaids Elbow see 1-3YO when
adult swings child
by arms or pulls
on them suddenly
-Partial dislocation of
proximal radioulnar joint.
-Traction of arm while
elbow extended; sublux
radial head
-Annular lig slides over head
of radius and gets trapped.
-pain w elbow movement; limited ROM
-Sign: holding arm in slight elbow flexion,
despite no swelling and refuses to move
arm
tenderness over elbow joint
CR normal
No meds
Reduce joint
dislocation: support
radial head, suppinate
and flex forearm at same
time until click
Prog: can reoccur
Wrist/Hand RA affects MCP, PIP,
and thumb
interphalangeal;
usually spare DIP

joint fusion occurs
if severe
Inflamed synovium
damages flexor/extensor
tendons
-ulnar deviation (u drift) at
MCPs of fingers
--swan neck (hyperextend
PIP w flexion at DIP)
--boutonniers (flexed PIP w
hyperextended DIP)
Local pain hands/fingers, in MCP/PIPs
bilaterally, gradual onset deep aching
throbbing in joints, pain w/ movement,
swelling, warmth and morning stiffness,
RA nodules (small firm nodules)
Spare DIP joints; ROM limited due pain
and structural damage/deformities
CR Diagnostic
NSAIDs, antirheumatic
agents, cold packs, joint
protection w/ splints,
paraffin wax, contrast
bath, use assistive
device for house
work/activities,
corticosteroid injections,
surgery for tendon
rupture,
Prog: fair to poor;
progressive w pain
&func
Hand Osteoarthritis
(OA) aka
degenerative joint
disease



PIP, DIP, CMC joint of thumb
progressive cartilage
degen
--Bouchards nodes (bony
nodule PIP joints)
--Heberdens nodes (bony
nodules DIP)
(bone gets damaged, so tries
to repair w
hypertrophynodes)
Localized pain @ base of thumb or
PIP/DIPs, gradual onset pain progresses
to constant pain w/ repeated hand pain;
pain w/ rest and ice application -
stiffness and swellingdiff to grip
- joint deformity, muscle atrophy from
disuse, ROM bc pain/stiffness
reproducible pain over affected joints,
CR: non-uniform joint space narrowing,
bone sclerosis, osteophytes
NSAIDs
Hand therapy w/
paraffin wax and
contrast baths,
protective splinting,
corticosteroid injections
Prog: Fair: progressive
condition; provide pain
relief and prevent
further injry
Scapholunate
Dissociation
Most common
carpal instability
Tear of intercarpal ligs of
lunate/scaphoid/capitate
bonesabnormal
movement of carpal bones
wrist instability and early
Acute to gradual onset wrist pain over
scapulo-lunate junc, Possible trauma
from sudden wrist hyperext, or repetitive
use injury. Swelling or weak grip, clicking
of wrist, ROM limited especially flex/ext,
NSAIDs
Temp immobilization of
wrist in neutral position,
surgery if pain persists
Prog: fair to poor, pain

OA tenderness over scapholunate
CR may show gap btwn scaphoid and
lunate >2 mm
imprv w/ treatment, but
gradual loss of ROM
despite surgery
Muscles/Tendons
Medial Epicondylitis

NOTE: Tendonitis:
resist contraction or
stretching it will hurt!
Hurts palpate over
tendon and if bad
enough muscle too
Corticosteriod
injection: not 1
st

resort, but help take
away pain from
inflame; yet still have
deconditioned muscle
so need to
stretch/work muscle
Golfers elbow
(adults) and little
leaguers elbow
(kids)
Overuse of wrist
flexors/pronators of
radioulnar joint. Common
flexor tendon gets inflamed

Gradual prog w/ more pain over medial
epicondyle that radiates to forearm.
pain w/ lifting, wrist flexion
pain w rest
Usually normal inspection, passive ROM
at elbow and wrist normal, but active
ROM is limited due to pain. Tenderness
over medial epicondyle
--Resisted wrist flexion and pronation
will produce pain. passive wrist ext w/
elbow extended causes pain. CR normal
unless tendon calcification
NSAIDs, PRICE
Stop painful activity,
counterforce brace distal
to elbow to distribute
tension/fulcrum, brace
flare on side of injury;
PT
Corticosteroid injection
Prog: good normally
resolves w/ conservative
treatment and
prevention future injury
Surgery if no impove 6-
12months
Lateral Epicondylitis ECRB tendon
(extensor carpal
radialis brevis)
most involved bc
smaller muscles
worked more
Tennis elbow
Overuse of wrist
extensors/supinators
muscles of proximal
radioulnar joint . Common
extensor tendon gets
inflamed.
pain over lateral epicondyle, forearm
pain w/ wrist lifting/ motion/extension
and w/ rest,
Passive ROM normal but active ROM
limied to pain.
--Resisted wrist ext/supination will
reproduce pain
CR normal unless tendon calcification
Same as above
Olecranon Bursitis

Resting elbows
on desk while
studying!!
subject elbow to
acute or repetitive
trauma
Swelling of olecranon
bursa found btwn
olecranon process of ulna
and skin
located in
posterior
elbow
Onset gradual, mod-severe local pain w/
any pressure or elbow motion, posterior
elbow pain. if acute, pain might be sharp
and radiating to posterior forearm,
Soft tissue swelling over olecranon,
maybe erythematous ROM limted to pain,
posterior elbow tender.
CR usually normal
NSAIDs
PRICE
Apsiration can reduce
swelling or rule out
septic bursitis or gout

Prog: most recover
spontaneously
DeQuervain
Tenosynovitis
Distinguish from OA
bc if DeQuervain
severe enough cause
pain along entire
tendon and not just
base of thumb like OA
does
Often confused
with OA of CMC
joint of thumb
Inflamm of EPB (extensor
pollicis brevis) and APL
(abductor pollicis longus)
(SEX LAB) on radial side of
wrist.
Repetitive/cumulative
trauma to tendons from
repeat ext/aBduction of
thumb. When tendon
sheath healsget dense
fibrous tissue that thickens
sheath and obstruct tendon
movement.
Pain/tender on radial side of wrist over
radial styloid process and at CMC joint of
thumb.
-Constant throbbing aching w/
superimposed sharp pain during thumb
movements. Pain iw/ pinching,
grasping, making fists. w/ rest, heat/ice
-Swelling over distal radius, limited ROM
in thumb and wrist; Crepitus palpable
when pt. flexes actively and extends.
Finkelsteins testreproduce pain
when pt bend thumb across palm, close
fingers over thumb making fist, and ulnar
deviate the fist
CR to rule out OA
NSAIDs
Rest thumb/wrist, avoid
repetitive wrist motions,
thumb spica splint to
immobilize tendons
Corticosteroid injection ,
sometimes surg
Prog: good full
functioning after
treatment. Normal
activity after 3 weeks
Trigger Finger Palpable/audible
snapping when pt
flex/extends
fingers. More often
women > 40 w/ hx
of diabetes or RA
Using gardening
shears
Presence of inflammation
of FDS (flexor digitorum
superficialis) or FDP (flexor
tendon profundus) tendon
sheaths of fingers
(tenosynovitis). Tendon
sheath swells and gets
caught in narrow
osteofibrous sheath anterior
to MCP
Gradual onset of mild-mod pain
pain after prolonged period of
inactivity or repeated activity of hand
that involve gripping or tapping
Swelling and small nodule at MCP,
extension limited to pain, fingers tend to
lock as they extend, nodules might be
palpable over MCP joint in palm, tender.
CR normal
NSAIDs
Rest finger w/ or w/o
splint, treat inflamma
Corticosteroid injection
swelling in sheath
Sometimes surg to
widen osteofibrous
tunnel
Prog: good most
improve w/ conserv
treatm
Nerves/Vessels
Carpal Tunnel Most common Median nerve compressed Dull aching pain in wrist might extend to NSAIDs, opioids
Sydrome

NOTE: if nerve pain,
palpation of muscle
will not reproduce
pain unless pushing
on nerve

Tingling and numb of
thumbCarpal tunnel
OR C6 radiculopathy?
Tinel +carpal tunnel
C6other symptoms
also (widespread
sensory/motor
symptoms; numb C6
dermatome, muscle
weakness
deltoid/biceps,
+spurling test)
compression
neuropathy in
upper extremity
Typing,
hairstyling,
gardening

10 things in carpal
tunnel: 4 FDS, 4
FDP, median
nerve, flexor
pollicus longus
tendon
under transverse carpal
ligament (flexor
retinaculum) forming roof
of carpal tunnel.
Pain/tingling/numbness/bu
rning in thumb, index,
middle finger
nerve will die from
compression and if nerve
dies, nothing controlling
muscles, so muscles atrophy
forearm and arm; MOTOR +Sensory
-thumb/index have paresthesia, esp on
wakening, pain typically worse at night
bc ppl sleep w flexed wrists (compress
further).
--Sensation at volar pads of thumb,
index and middle fingers from
compression. ROM normal, pain over
wrist
Tinels sign at wrist (light percussion
over nerve to elicit tingling/pins&needles
Phalens sign (pt push dorsal surfaces of
both flexed hands together for 60sec+
if burning, tingling sensation thumb,
index, middle finger
EMG gold standard &nerve conduction
CR usually normal
Wrist braces/splints, US
heat, ergonomics,
Corticosteroid and
surgical release flexor
retinaculum
Prog: good if early detec,
bad if left untreated;
pain and weakness
Peripheral
Neuropathy
SUMMARY: Ulnar nerve: C8/T1
radiculopathy (lower trunk)cubital
tunnel at elbowguyons tunnel

Cubital Tunnel
Syndrome

(Note: a radiculopathy
would usually has
neck pathology
present/paraspinal)
Ulnar nerve
entrapment when
cross ulnar groove
Ulnar nerve (branch medial
cord) compressed in
cubital tunnel or in band of
aponeurosis btwn proximal
heads of Flexor carpi
ulnaris muscle
Pain follows ulnar distribution;
numb/tingling/burn/weak grip 4
th
and
5
th
digits; weak hypothenar and hand
intrinsic muscles (lumbricals/interossei
Tinel test +: taping nerveworse pain
Nerve Conduction Study for dx
Palpating forearm should NOT cause pain

Guyon Tunnel
syndrome

Ulnar nerve compressed
w/in guyon tunnel at
wrist; ulnar side
Btwn hook of hamate and
pisiform
Bifurcation into superficial (sensory) and
deep (motor) branch. If compression
before bifur, both affected, if after bifur,
only deep branch/motor deficit
observed; weakness hypothenar muscles

Radial Tunnel
syndrome; Posterior
interosseous nerve
syndrome
might not have
pain, may just be
weakness in
extensor muscles;
if do have pain,
commonly
confused w lateral
epidonyltitis
Compression of radial
nerve distal to lateral
elbow/epicondyle over
supinator where divides to
superificial and deep radial
nerve which penetrates
supinator to become post.
interosseus nerve
Predominantly MOTOR neuropathy
Weakness in elbow supination (but can
still do bc supinator innervated deep
radial nerve) and finger extension (ESP
Middle finger). No weakness proximal to
elbow. Dull, aching pain over lateral
elbow, but otherwise no sensation s.
Diagnose w nerve conduction study and
EMG

Hip & Knee
Bones-
Fractures/Dislocate

Acetabular Fracure Less common fx;
elderly at risk bc
osteoporosis
MVA or fall; Direction
/magnitude of force and
position femoral head
determine fx pattern

Avascular Necrosis
(AVN)-Femoral Head
Lack of blood 2
to trauma,
diabetes, sickle
cell, SLE, chronic
corticosteroid use
Cellular death of bone from
lack blood supply
Initially,
asymptomatic
After progression,
bone collapse and hip
joint destroyed
Total hip replacement
Posterior Hip
Dislocation
More common
than anterior
Blunt force trauma from
MVA on pedestrian or fall
from height
Lower extremity internally rot. &
aDducted.
Sciatic nerve compressed by femoral
head

Femur
Intertrochanteric Fx
Elderly pts;
trauma,
osteoporosis
different from neck fx (above
trochanteric line)
leg becomes shortened bc
pull of gluteal muscle
tendons; also Ext Rot and
Abducted
Damage to circumflex femoral
arterycommon post-traumatic
complication of AVN of femoral head

Toddler Fracture 1-3YO; accidental
fall after foot
entrapped
mid-shaft oblique fx of tibia;
spiral from
twisting/torsional injury
lower extremity
Swelling/warmth over fx site;
Child will refuse to walk/bear weight on
damaged limb; may not be visible on CR;
usually purely mechanical patholgoy

Patellar Fracture Direct or indirect
trauma; most
common
transverse fx
Jumping or eccentric
contraction of quads; or fall
on knee cap; trauma
anterior knee
Swelling anterior knee,
bruising, possible
abrasion
Limited ROM, inability to
flex knee

If unable to do straight
leg raise testsurgery
Full recovery
If vertical fx, usually no
surgery needed bc
tendons pull tight
Tibial Stress
Fracture
most common
location stress fx;
Bone repair unable to keep
up w repetitive trauma;
bone damagestress fx;
unbalance remodeling
Pain over medial aspect of tibia (shin
splints); gradual onset painconstant
Pain=localized, deep ache; reproduced
hopping or jumping on leg; pain after
weight-bearing, pain w rest, ice, NSAID
ROM knee, hip, ankle=normal
MRI gold standard for dx, CR helpful

Legg Calve Perthes
Disease
Idiopathic (no hx
trauma) AVN of
femoral head;
young caucasion
boys 3-12yrs
Usually unilateral, change
in blood supply at head in
childhoodrisk AVN from
mechanical or infectious
insults
Mild hip/knee pain w limp
Initial: CR normal
Degenerative phase: flattened femoral
head
Regernative phase: head re-ossifies and
no longer fits normally into acetabulum
ROM: Int Rot and aBduction hip
Prog: good

Osgood Schlatter
Disease
Knee pain in 10-
15YO; pts who
jump or sports
Repetitive
pulling on
patellas
tendon at
insertion on
tibia tubercle;
may cause
avulsion fx
Anterior knee pain w time
Prominence at tubercle w assoc
effusion and warmth
ROM normal; pts may avoid knee flexion
bc pull on patella tendon
Tender over tendon;
CR not for dx
NSAIDS, ice, limit
activity that exacerbates
Stretch/strenghten
quads and hams
Surgery rare
Prog: good; resolves 1
year
JOINTS
Hip
OA
Femur head and
acetabulum

Causes: previous
fxchanges hip alignment;
undiagnosed hip dysplasia;
AVN fem head
-pain in groin (dull aching, throbbing, or
sharp, stabbing); tender inguinal area
-antalgic gait (limp)
-ROM limited; esp Int Rot and Abduct
-test pain w Int Rot hip (LOSE Int Rot 1
st
)
CR: non-uniform JSN, sclerosis, ostephyte
NSAIDS, opioids (severe)
Modify lifestyle, PT
strengthen muscles
across hip joint
Corticosteroid inject
PROG: fair/poor
Developmental hip
Dysplasia
Uni- or bilateral;
genetic link
Unbalanced fit femoral head
& acetabulumposterior
Dx: physical newborn infants; asymmetry
gluteal region, thigh, labial folds
No meds, Pavlik
harness (prevent

2x more girls subluxation fem head

ROM: limited Abduct
Ortolani & Barlow Maneuver: + if click or
dislocate infant hip when aBduct w
anterior pressure
CR conclusive (red arrow), acetabulum
is shallow, not really carved out.
ADDuct and Extension)
Brace is to do aBduct
and carve out cup
If late dx; req traction
and surgery
Prog: Fair; if early dx
(1
st
wks postnatal) then
reverse condition; if no
treatpt gets OA early
Slipped Capital
Femoral Epiphysis

During teen, plane
of growth plate
femoral head
changes
orientation to be
in alignment w
direction weight
bearing forces; 11-
16YO white boys
Orientation change subjects
growth plate to greater
disruptive shearing forces
from activities; mechanical
stress and hormonal
imbalance in pubertyrisk
for displaced, Salter Harris
Type I fx of epiphyseal plate
fem head; shifts head of
femor. Can be Uni- or
bilateral; ice cream falling
off cone
Pain: sharp/severe in groin after injury;
radiate to butt and knee; w hip
movement and weight bearing
Leg is Ext Rot and limping
ROM: Int Rot
and Abduct
CR conclusive
Rare to have
AVN bc ped
femoral head
good circulation from ligamentum teres
(which lessens in adults)
NSAIDS, strength
training after
surgeryscrew;
surgical pinning.
PROG: Fair
Most pts functional after
surgey; but risk for early
OA
Toxic Synovitis Boys 3-7YO Unknown cause aka
Transient Synovitis bc
transient clinical
presentation; ACUTE onset,
overnight
Acute pain, limp for 3-5 days; palpation
does NOT produce pain; joint effusion
cause femur to pop out of socket and
uncomfortable
ROM: limited Int Rot from pain
Presents commonly in morning; pt
typically NOT sick
CBC and ESR normal, CR normal
NSAIDS, rest
PROG: good, resolves on
own
Knee OA



>55YO or younger
if hx trauma; assoc
w other problems
(meniscus or
ligament tear,
prior fx), obesity
Medial compartment (most
common, but all 3 possible
(lateral and patellofemoral)
-bow-legged from degen of
medial femorotibial
articulation
-varus: distal bone points
toward midline
-valgus (knock-kneed)
-Bilateral; dominant pain one side; limp;
tender over joint
-gradual, intermittent painconstant;
w weightbearing
activities, rest
-knee stiffness, esp after
activity
-ROM: restricted
flex/extend, pain at end of
-NSAIDS opioids
-Lifestyle modification:
exercise, PT and weight
-brace (stability), cane
opposite side (off load
weight), shoe wedges
(correct varus or valgus)
corticosteroid inject
(pain/inflamm),
distal bone points away
from midline of body
ROM; crepitus palpated w ROM
CR: marginal osteophytes, sclerosis, non-
uniform JSN
eventual total knee
replace
PROG: fair to poor
Patellofemoral
Syndome
Knee pain young
adult
s
Overuse, overload, muscle or
biomechanical problem of
patellofemoral joint; loss of
smooth patella gliding over
femoral condylesgrinding
retropatellar surface on
femur;
ROM: limited knee flexion
Gradual onset anterior knee pain due to
repetitive movement patella over femur;
tender lateral aspect patella w palpate
-dull ache, swelling, click of
patella/crepitus; follow tracking patella
pain climbing stairs, walk, run,
prolonged sitting and standing from seat;
pain w rest.
Assoc. w strength quads, offset patella,
swollen knee joint
Atrophy vastus medialis muscle
CR normal
NSAIDS
Rest, cold, brace/tape,
strengthen quads
Last resort surgey
PROG: good
Tibial Torsion Genetics or
positioning of leg
in uterus; self
corrected
rotation by age 2
via walking
During development after
birth, tibia turns in or out
toeing-in/pigeon toe
=Internal torsion; ankle
&foot also turn

NO pain
toeing-in gait, occasional tripping
ROM: normal
Can measure angle between thight and
foot (normal is w/in 10deg)
No need CR
Observation, potential
night time splint to help
correct
Surgery req if do not
resolve
PROG: good
Muscles/Tendons
Trochanteric
Bursitis
Runnersacute,
repetitive trauma

Painful inflamm of bursa
btwn greater trochanter and
insertion gluteus maximus
tendon; IT (iliotibial band;
thickening of facia lata)
becomes tightpressure on
bursa
Stretching IT band
reproduce pain
Gradual, pain lateral hip, swelling
Deep ache constant deep pain
pain pressure on lateral hip, walking,
running; palpate pain IT band and
greater trochanter;
ROM: normal; CR normal
NOTE: If have referred groin and knee
pain w passive Int Rot of hip
jointmore likely hip joint path (ex OA)
and not this
NSAIDs, rest, ice (acute)
PT: stretch IT band (pics
Chronic: deep heat (US)
Assess gait
abnormalities and
address w assistive
devices (ex. Cane)
Corticosteroid inject into
bursa
PROG: good
Pes Anserine
Bursitis

Irritation/inflamm of pes
anserine bursa at medial
knee
Pes anserine (common
tendon gracilis, Sartorius,
semitendinosus)
Tender palpate over bursa, but NOT over
joint line or patella; may reproduce pain
w passive knee extension
Mild swelling or normal at medial knee
below joint line
ROM: normal
CR: normal
NSAIDS
Ice, lower extremity
stretching
Corticosteroid inject
Prog: Good
Meniscal Tear

Crescent shaped medial and
latereal menisci; provide
shock absorption. Tear
when foot is planted and
knee twisting (common
football, bball, skiing)
If medial meniscus is
injured, risk tear of MCL
since its attached to medial
meniscus
Acute injurymild swelling, pain >24hrs
If degen changes cause teargradual
onset pain, w time
Mild to mod pain, dull ache; but SHARP w
twist or bend
popping, clicking, catching assoc. w
joint effusion; locking/pain w squat
ROM: limited extend, pain w full flexion
Effusion/tenderness at joint line
McMurray test: meniscal tear
perform on ACL, PCL, MCL, LCL to rule
out addl lig injury

NSAIDs
Initally: activity, ice,
crutches if severe pain
Later: quads and hams
muscle strengthening
exercises
Surgery if ACL tear also
or locking from flap of
meniscus getting caught
Prog: good to fair
depending on severity;
risk OA
Knee Ligament Tear

4 ligs:
ACL: prevent ant.
translation of tibia
PCL: prevent post.
translation of tibia
MCL: medial knee
stability
LCL: lateral knee
stability

ACL tear: MOST COMMON
from high impact jumping,
twisting, impact on lateral
side knee while foot
planted; audible pop,
swelling 1hr
PCL tear: dashboard
injurieshit tibia from front
while bent knee and pushes
it back
MCL tear: excessive valgus
LCL tear: excessive varus
unhappy triad/terrible
triad injury=MCL, ACL,
medial meniscus tears;
clipping injury (
IMMEDIATE pain following maneuver;
initially sharp/severe and softens to dull
ache, ACLACUTE swelling
pain/instability w strenuous, hard-
impact activities (climb, run, jump); knee
gives out
hemiarthrosis, effusion
ROM: limited flex & extend
ACL tear: Lachman and anterior drawer
test; blood in joint
PCL tear: posterior drawer test
Valgus (for MCL) and varus stretch (for
LCL ) laxity
MRI gold standard for ligaments
NSAIDS, ice
PT: proprioception
training, ROM exercises,
quads and ham
strengthening to
stability; use brace
Surgical reconstruction
(grafts or cadaver) for
ACL tear
PROG: Good: pts w PCL,
MCL, LCL
Fair: untreated
ACLknee
instabilityrisk degen
NERVES/VESSELS
Compartment Limb and life Perfusion pressure drops Acute onset following injury IV hydration
Syndrome threatening;
Common lower
limb
below tissue pressure in
closed anatomic space;
compartment pressure
builds from swelling
(trauma, tight casts, etc) or
bleeding.
tissue necrosis,
permanent func
impairment,
rhabdomyolysis (excessive
tissue damage) that can
progress to renal
failure/death
Chronic: repeated low intensity
traumarecurrent and progressive pain
SUSPECT whenever significant pain
occurs in extremity following an injury
pain w movement, nerve impairment
cause severe pain/burning
nothing pain
extremity: swollen, w or w/o pallor; may
feel warm or cold, eventually
tenses/hardens as if filling w fluid
pain passive stretching of muscles
CR not dx
O2 given bc ischemic
injury; hyperbaric O2 if
available
Do NOT elevate
extremity-will worsen
ischemia
Fasciotomy-cut fascia
PROG: Good if
fasciotomy done w/in 6
hrs
Poor: necrosis occurs
>6hrs
Peripheral
Neuropathies



Lateral Femoral
Cutaneous Nerve
Syndrome
Compressed nerve at lateral
edge of inguinal ligament
Burning, numbness, parestheia down
proximal-lateral thigh

Piriformis Syndome Sciatic nerve
enters gluteal
region via greater
sciatic foramen
deep to piriformis
If piriformis
tightenscompresses
sciatic nerve
Pain referred to gluteal region and
posterior thigh compartment, deep pain

Common Peroneal
Nerve Entrapment
MOST common
peripheral nerve
injury lower
extremity
Injured any locations along
thigh to fibular head
(trauma, laceration, femoral
fracture, bullet wound)
MOST injury at fibular head;
Nerve wraps around fibular head and can
be compressed here; can get compressed
from habitual leg crossing, or
compression against bed railing or
hard mattress for debilitated pt or
prolonged immobility (seen w pts under
anesthesia)

ANKLE/FOOT
BONES
Lateral Malleolar Fx Fx distal fibular;
ankle fx
Direct trauma or twisting
injury assoc. w ligament
injuries on medial
side(widening of joint); thus
search for multiple injuries
Bone tenderness at posterior edge and
tip of lateral malleolus
Inability to bear weight

Medial Malleolar Fx Fx distal tibia;
ankle fx
Landing from jump or
rolling ankle; large
traumatic force req such
that other injuries involved-
->torn deltoid lig
Sudden onset sharp, intense ankle pain
Walk w limp

5
th
Metatarsal Fx;
Jones Fx
Forceful
inversion of foot
concurrent w
contraction of
peroneus brevis
muscle
Avulsion fx of base of 5
th

metatarsal bone; transverse
or oblique fx
Pain and tenderness at base
5
th
metatarsal
Local bruising and swelling
Non-displaced fx treated
conservatively; surgery
for comminuted or
displaced or non-union
Calcaneus Fracture High-energy
injury; fall from
height; MVA,
sports
Initial
2weeks later
Swelling, pain over calcaneus and heel
pain
Subtalar Joint: btwn calcaneus and talus;
when calcaneus fx, lose
inversion/eversion of foot
Typically no effect on dorsi/plantar flex
risk OA at subtalar
joint
surgery
JOINTS
GOUT Common inflamm
monoarthritis;
deposition
monosodium
urate
monohydrate
crystals in joint &
periarticular
tissues; humans
non-func uricase
Serum urate >6.8mg/dL
(hyperuricemia)
Men>40YO
Uncommon premenopause
women
gout w obesity rates
EtoHgouty flares in
younger ppl`
25% 1
st
attacks will not
reccur in ppl
1
st
MTP jointpodagra; but
any joint susceptible
Asymptomatic hyperuricemia:
relatively common
Acute gouty arthritis: MSUM crytsals
ppt an inflamm response; rapid warmth,
erythema, swelling soft tissue, joint
effusion, pain at rest, active, and passive
ROM; may also get
tenosynovitisperiarticular
pain/swelling.
pain over 8-12hr period
attacks over time can involve more joints,
be more frequent, and longer duration
hematology: serum uric acid level is
not indicative and normal does not rule
out; many ppl no gout, but serum uric
synovial fluid: needle shape crystals,
negatively birefringent (blue
2 phases:
1) control inflammation
(colchicine, NSAIDS,
systemic steroids,
intraarticular steroid
injections)
2) lower serum uric acid
level (intake organ and
red meats, shellfiss and
high purine diet; also
consider meds
PROG: good to fair
perpendicular)
Radiology: takes years b4 develop;
erosions w punched out appearance and
sclerotic margin/overhangind edges
MUSCLES/TENDONS
Ankle Sprain Most common is
lateral sprain

Inversion (twising in and
upward) of foot; rolling
ankle inward
Anterior talofibular
ligament
Diffuse pain initially, then localize to
lateral aspect (ATF lig) or medial aspect
(deltoid lig) as swelling
Acute pain from trauma; initially
sharpdeep ache
pain w weight being and ROM; w rest
if severelocal swelling/bruising
ROM: active and passive painful
Palpate medial and lateral malleolus;
base 5
th
metatarsal and mid-foot bones.
Should NOT have bony point tenderness
(indicates possible fx then)
CR normal
NSAIDS
PRICE for acute
Braces/tape for
protection
Gradually progress back
to physical activities
Surgery for severe
sprains
PROG: good: mild
sprain
Fair: mod-severe lateral,
medial ankle sprain and
high ankle sprain
Plantar Fasciitis joggers heel,
tennis heel
policemans heel

Overuse of plantar fascia at
its attachment to calcaneus
bone from activities of max
plantar flexion of ankle and
dorsiflexion of MTP joints

Gradual onset inferior heel pain after
change in activity level, shoe, or surface
Pain w/ 1
st
few step in morning or
periods non-weight bearing
pain w stretching plantar fascia, walk
bare foot, or upstairs
Assess gait and shoes
ROM: ankle dorsiflexion may be limited
from tight Achilles tendon
point tenderness at medial process of
calcaneal tuberosity
CR: calcaneal spurs from chronic pulling
via plantar fascia
NSAIDS
PRICE, PT, strengthen
gastroc-soleus complex,
massage w friction.
Orthotic devices to
cushion heal and arch
support, night splints,
weight loss, modify
activity
Corticosteroid injection
Surgery (fascial release
or debridement)
PROG: good (80% cases
resolve spontaneuously
w/in 1yr
Achilles Rupture 30-50YO, 4-5cm
proximal to
calcaneus bone
where poor blood
flow to tendon
sudden strain
or direct blow
to tendon while
contractedDis
ruption of
Achilles tendon
Acute onset pain; shot, kicked or cut in
back of leg; swelling, instant weakness
Inability to walk
pain w weight bearing and palpation of
calf; pain w rest
ROM: weak/absent plantar flexion
Palpable defect in tendon
Thompson Test: pt lying prone w knee
passively flexed, dr squeeze calf and loo
for foot plantar flexion. + test if plantar
flexion ablest
CR not needed
NSAIDS
PRICE, PT for post-op
and post-cast care,
isometric ankle and
progressive resistance
exercises,
proprioceptive training
Surgical repair high level
athletes or if medical
therapy (crutch, non-
weight bearing, casting,
orthrotics) FAIL
PROG: good; but lose
some ROM
NERVES/VESSELS
Tarsal Tunnel
Syndrome
Most common
entrapment
neuropathy of
foot/ankle
Compression tibial nerve
posterior to medial
malleolus where travel
under flexor retinaculum
in tarsal tunnel
Paretheses of plantar foot, posterior leg
numbness, plantar flexion weakness, and
clawing of toes

Interdigital Neuritis AKA Mortons
neuroma;
irritated when
where high heels;
squeezing
metatarsal heads
together
Entrapment of plantar
interdigital nerve as passes
under transverse
metatarsal lig;
As weight transfer to ball of foot when
toes dorsiflexed during push off of gait,
nerve is compressed between plantar
foot and distal edge of lig













Special Testing
1. Spurlings Compression Test
a. Positive for cervical radiculopathy
2. EMG
a. Detecting particular nerve damage
b. Helps locate a particular nerve thats
involved
3. Leg Length Test
a. Sacroiliac Joint Dysfunction
4. Faber Test
a. Sacroiliac Joint Dysfunction
b.
5. Straight Leg Raise Test
a. Lumbar Radiculopathy
6. Babinskis Sign
a. Testing for spinal cord injury due to spinal
cord compression
b. Foot dorsiflexes and big toe extends when
rubbing the lateral side of the foot is positive
for neurological damage.
7. Sulcus sign
a. Shoulder Instability
b. Downward traction of humerus can see a
depression below the acromion
8. Hawkins Sign
a. Shoulder Impingement
b. Shoulder abducted 90 deg and elbow flexed
90 deg, internally rotate humerus, positive if
pain is ilicited
9. Neers Sign
a. Shoulder Impingement
b. Max passive abduction in scapula plane with
internal rotation while stabilizing scapula
will cause pain in the sub acr. Bersa or
anterior edge of acromion
10. Resisted Wrist Flexion
a. Medial epicondylitis
11. Resisted Wrist Extension
a. Lateral epicondylitis
12. Finkelsteins Test
a. DeQuervain Tenosynovitis
b. Cup thumb in fingers and ulnar deviate
positive if it ilicits pain
13. Tinels Sign at wrist
a. Carpal Tunnel (median nerve compression)
b. Percuss median nerve at wrist
14. Phalens Test
a. Carpal Tunnel (median nerve compression)
b. Push back of hands together for 1 min
c. Positive if it causes same symptoms













Table 1. Cervical Radiculopathy




Table 2. Lumbar Radiculopathy.