Student Guide to Common Orthopedic Injuries

Transcription

1 Student Guide to Common Orthopedic Injuries INTRODUCTION... 4 SHOULDER... 5 Shoulder Anatomy... 5 Glenohumeral (GH) Dislocation... 6 Impingement, Tendinopathy, and Rotator Cuff (RC) Tear... 6 Labral Tear... 7 Biceps Tendinopathy... 7 Acromioclavicular (AC) Separation... 8 Acromioclavicular (AC) Degenerative Joint Disease:... 8 Adhesive Capsulitis (Frozen Shoulder)... 8 Shoulder Special Tests Glossary... 9 ELBOW...12 Lateral Epicondylitis (Tennis Elbow)...13 Medial Epicondylitis (Golfer s Elbow)...13 Olecranon Bursitis...13 Ulnar Collateral Ligament (UCL) Tear...14 Ulnar Nerve Entrapment...14 Biceps Tendon Rupture...14 Posterior Elbow Dislocation...15 Brief Notes on Elbow Fractures:...15 WRIST/HAND...16 Scaphoid Fracture...16 Distal Radius Fracture...17 Triangular Fibrocartilage Complex (TFCC) Tear/Sprain...17 Carpal Tunnel Syndrome...18 De Quervain s Tenosynovitis...18 Carpometacarpal Osteoarthritis (CMC OA)...18 Thumb Ulnar Collateral Ligament (UCL) Sprain/Tear...19 Trigger Finger (Stenosing Flexor Tenosynovitis)...19 Mallet Finger...20

2 Dorsal PIP Dislocation...20 Hand/Wrist Special Test Glossary...21 HIP...22 Hip Osteoarthritis...22 Femoral Fractures...22 Femoral Neck Fracture (Intracapsular)...22 Intertrochanteric Fracture (Extracapsular)...23 Avascular Necrosis (AVN or Osteonecrosis) of Femoral Head...23 Greater Trochanteric Pain Syndrome...24 Femoroacetabular Impingement (FAI)...24 Hip Flexor Strain...25 Internal Snapping Hip Syndrome (Iliopsoas Tendonopathy) (Internal Coxa Saltans)...25 KNEE...27 Osteoarthritis...27 Anterior Cruciate Ligament (ACL) Tear...27 Medial Collateral Ligament (MCL) Tear...28 Posterior Cruciate Ligament (PCL) Tear...28 Lateral Collateral Ligament (LCL) Tear...28 Meniscal Tear...29 Patellar Dislocation...29 Patellofemoral Pain Syndrome...29 Iliotibial Band (ITB) Syndrome...30 Patellar Tendinopathy (Jumper s Knee)...30 Prepatellar Bursitis...31 Popliteal (Baker s) Cyst...31 Knee Special Test Glossary:...32 ANKLE Ankle Sprains Lateral Sprain Medial Sprain High Ankle Sprain (Syndesmotic) Osteochondral Defect (aka Osteochondritis Dessicans) Distal Fibular Fracture... 34

3 Posterior Tibial Tendinopathy Peroneal Tendinopathy Ankle Special Test Glossary FOOT Hallux Rigidus Hallux Valgus (Bunion) Jones Fracture Lis-Franc Injury Stress Fractures Midfoot Arthritis Morton s Neuroma BACK/SPINE...41 This study guide is designed to help students to begin formulating differentials for musculoskeletal pain and injuries while learning the musculoskeletal exam. It is in no way meant to be extensive, and presents only the most common and straightforward presentations for the injuries covered. First-year and second-year students should focus on the history and physical sections of each injury. The imaging and treatment sections are included primarily to serve as a reference.

4 INTRODUCTION Basic Ortho Principles to keep in mind 1. Inspect first. Is patient guarding the limb?. Is there asymmetry, muscle atrophy, or bony deformity? 2. Neurovascular exam. Assess sensation, motor strength, pulses, and capillary refill, particularly in the setting of trauma. Remember the 6 Ps of compartment syndrome: paresthesia, paralysis, pain, pallor, poikilothermic (cold), pulseless. 3. Examine the joint above and the joint below. E.g., if shoulder hurts, assess neck and elbow as well as shoulder.. Knee: assess hip and ankle. Basic terminology: Dislocation: Injury to the joint that forces one or more bones out of position. To describe the type of dislocation, refer to the position of the distal bone. E.g., posterior elbow dislocation means ulna has moved posteriorly in relation to humerus. Bursa: Small jelly-like sac containing synovial fluid that lies between bone and soft tissue and provides cushioning or lubrication. Bursitis, an inflamed swollen bursa, may develop due to overuse of friction. (E.g., a person who cleans for a living kneeling on a wood floor may develop pre-patellar bursitis.) Tendonitis: A type of tendinopathy where there is inflammation of a tendon. Paresthesia: Tingling, pricking, tickling, or burning sensation of a person s skin with no chronic physical effect. Pins & needles (e.g., foot falling asleep).

5 SHOULDER Things to remember for shoulder pain evaluation: 1. Rule out referred pain (cardiac, diaphragm, gallbladder, spleen). 2. Evaluate the joint above and below (neck/elbow). 3. Perform neck, neurologic, and vascular exams. 4. Evaluate scapulothoracic movement for asymmetry, which may contribute to shoulder pain. Note: If history of trauma, x-ray to rule out fracture. Shoulder fractures otherwise not covered here. Shoulder Anatomy 3 bones: Clavicle Scapula (acromion, coracoid process, glenoid fossa) Humeral head Glenohumeral joint is stabilized by static and dynamic stabilizers. Static stabilizers include

6 the labrum a fibrocartilaginous cup that deepens the socket (glenoid fossa), glenohumeral ligaments (superior, middle and inferior), coracohumeral ligament, and biceps tendon. Dynamic stabilizers include the 4 rotator cuff muscles: supraspinatus, infraspinatus, subscapularis, and teres minor. Glenohumeral (GH) Dislocation Anterior dislocation is much more common than posterior dislocation. History: Often due to fall or trauma with the arm abducted and externally rotated. Patient may also have chronic shoulder instability with frequent dislocations bilaterally. Physical exam: Inspect for deformity, arm externally rotated. Positive apprehension test is suggestive of shoulder instability. Imaging: Plain radiographs including A/P view, Y view, and axillary view. Evaluate for associated injuries such as fractures. Treatment: If unilateral and secondary to trauma, patient may require surgery to prevent recurrence. If atraumatic and bilateral instability, start with physical therapy for patient. Complications: Axillary nerve injury, instability and repeat dislocations, cortical depression of humeral head (Hill Sachs lesion), labral disruption and bony avulsion (Bankart lesion). Posterior dislocation is uncommon and usually associated with electric shock, seizure, or high velocity trauma. Physical exam may show obvious deformity with lack of external rotation. Treatment is immediate reduction and immobilization. Impingement, Tendinopathy, and Rotator Cuff (RC) Tear Shoulder impingement is compression of structures between the acromion and glenohumeral joint. Rotator cuff tendons, subacromial bursa, labrum and/or biceps tendon are the most commonly affected structures. Risk factors include GH instability, repetitive overhead activity, and age.

7 History: Insidious onset, increased pain with overhead activity, night pain, and pain radiating to deltoid. Physical exam: Impingement: Full active and passive range of motion (although may be limited by pain). positive Hawkins-Kennedy (pain with passive flexion and internal rotation) positive Neer (passive arc), active painful arc (>90 degrees) RC tear: Full passive but decreased active range of motion. Most commonly torn muscle is supraspinatus due to direct pressure from acromion. supraspinatus: empty can test, isometric abduction infraspinatus: external rotation subscapularis: lift off, internal rotation Imaging: Ultrasound. MRI if concern for RC tear. Treatment: Limit flexion of GH joint to <90 degrees. Physical therapy to increase rotator cuff strength. NSAIDs. Refer to ortho for RC tear. Labral Tear The glenoid labrum (glenoid ligament) is a fibrocartilaginous cup that deepens the glenoid fossa. Labral tear is common in overhead athletes such as gymnasts and swimmers, or after traumatic fall or dislocation. Superior labral anterior to posterior (SLAP) most common and is often associated with proximal biceps tear. History: Deep, poorly localized shoulder pain and instability, catching sensation with movement Physical exam: Pain with compression of GH joint and pronation. Imaging: MRI Treatement: NSAIDs. Physical therapy to improve strength and range of motion. Surgery if pain does not improve with non-surgical management. Biceps Tendinopathy Long head of biceps originates intra-articularly at the superior glenoid tubercle. Biceps supinates and flexes the arm at the elbow. Biceps tendinopathy is most commonly secondary to shoulder impingement or shoulder instability. Risk factors include repetitive pulling, lifting, reaching, or throwing.

8 History: Anterior shoulder pain that may radiate to the bicep. Worse with flexion and supination. If tendon rupture, patient may hear a pop followed by weakness or swelling. Physical exam: Bicipital groove tender to palpation. Positive Speed s test. If tendon rupture present, then popeye deformity (enlarged distal biceps muscle) and weakness Imaging: Ultrasound to evaluate for tendinopathy. MRI for severe injuries. Treatment: Rest, ice, NSAIDs, glucocorticoid injection. Ortho referral if patient is an athlete, or work requires arm strength, particularly for biceps tendon rupture. Acromioclavicular (AC) Separation Injury to the AC joint ranges from mild sprain of AC ligaments to severe disruption of AC ligaments, coracoclavicular ligaments, and muscular attachments and displacement of the clavicle. History: Common in contact sports after falling onto the superior or lateral aspect of the shoulder. Physical exam: AC joint tenderness. Pain with passive adduction across the chest (AC compression). Imaging: Radiograph- AP view, arm internally rotated with comparison view of unaffected side. Treatment: depends on the severity of the injury. Involvement of AC ligaments only or partial CC ligament is treated conservatively with rest, ice, sling followed by rehab. Orthopedic consult for more severe injuries. Acromioclavicular (AC) Degenerative Joint Disease: History: Often asymptomatic. If symptomatic, typically presents with pain over deltoid, trapezius, AC joint. Worsens with overhead or cross body movement (adduction) Physical: AC joint tender to palpation and enlarged. Pain with passive adduction (scarf test). Imaging: Plain radiographs to assess for changes consistent with osteoarthritis Treatment: conservative (activity modification, ice, nsaids). Consider referral to orthopedics if no improvement. Adhesive Capsulitis (Frozen Shoulder) Stiffness thought to be caused by adhesions and fibrosis of synovial lining with thickening and contraction of GH joint capsule leading to reduced joint volume. Although the condition is painful, the decreased range of motion is mechanical, not secondary to pain. Risk factors include diabetes, autoimmune conditions and prior shoulder injuries basically, things that predispose to inflammation.

9 History: insidious onset of shoulder pain and stiffness, may be worse at night. Stiffness may limit daily activities (unable to put on a coat, etc.) Physical exam: limited active and passive range of motion. Imaging: radiograph to rule out osteoarthritis. Treatment: Condition is usually self-limited, but may persist for years. Conservative therapy with analgesics, gentle range of motion exercises, glucocorticoid injections if no improvement. Refer to orthopedics after months if no improvement. Back to Table of Contents Shoulder Special Tests Glossary Apprehension test: Patient lying supine with arm off table. Elbow flexed to 90 degrees and shoulder abducted to 90 degrees. Apply gentle force of external rotation to the arm. Positive test is apprehension of the patient, not pain. (They may ask you to stop for fear of dislocation) Back to Shoulder Dislocation Hawkins-Kennedy: Passive flexion of elbow and shoulder to 90 degrees (in neutral position). Examiner applies force of internal rotation to shoulder. Pain= positive suggesting supraspinatus impingement. Back to Impingement/RC Tear Neer test: stabilize patient s scapula. Pronate (internally rotate) the patient s arm and forward flex as far as possible up to 180 degrees. Pain = positive. Back to impingement/rc Tear

10 Empty can: Have patient raise straight arms to degrees with internal rotation (thumbs pointing downward) and apply downward pressure. Weakness is suggestive of RC tear. Back to impingement/rc Tear Lift off: arm internally rotated with dorsum of hand against the back. Ask patient to push posteriorly against resistance. Weakness indicates subscapularis injury. Back to impingement/rc Tear Speeds test: Elbow straight, arm supinated and flexed to 90 degrees at the shoulder, pain in the bicipital groove with resistance to downward pressure) Back to Biceps Tendinopathy Scarf test: Elbow flexed to 90 degrees and adduct the patients arm, placing the patient s hand on his/her opposite shoulder.

11 Back to AC Degenerative Joint Disease

12 ELBOW Anatomy Review: Medial epicondyle is the origin of wrist flexors. Lateral epicondyle is the origin of wrist extensors. Ulnohumeral joint flexes and extends. Radiohumeral joint supinates and pronates.

13 Lateral Epicondylitis (Tennis Elbow) Recall that wrist extensors originate at the lateral epicondyle and wrist flexors originate at the medial epicondyle. Lateral epicondylitis is most often a tendinopathy of the extensor carpi radialis brevis at the lateral epicondyle. History: patient complains of localized pain at the lateral epicondyle with extension of the wrist. Physical exam: point tenderness at lateral epicondyle. Pain with resisted wrist extension. Full active and passive range of motion at the elbow. Note: effusion should not be present, as epicondylitis is an extraarticular process. Imaging: usually not indicated Treatment: Activity modification to limit repetitive motion. Physical therapy. Modifying athletic techniques. NSAIDs. Counterforce bracing. Consider referral if no improvement with 6 months of non-operative management. Medial Epicondylitis (Golfer s Elbow) Less common than lateral epicondylitis. Tendinopathy of pronator teres and flexor carpi radialis at the medial epicondyle. History: pain with wrist flexion and supination. Physical exam: Medial epicondylar point tenderness to palpation. Pain resisted pronation of the forearm and resisted wrist flexion. Treatment: Activity modification to limit repetitive motion. Physical therapy. Modifying athletic techniques. NSAIDs. Counterforce bracing. Consider referral if no improvement with 6 monthf non-operative management. Olecranon Bursitis Swelling of the olecranon bursa. Acute: due to trauma or infection Insidious: due to chronic irritation History: Patient complains of swelling and pain over olecranon with pressure. Physical exam: Effusion over olecranon, tenderness over olecranon, full active and passive ROM

14 Caution: if there is inflammation (redness, heat, swelling) and decreased range of motion, then you should be concerned about synovitis (inside the joint, as opposed to the bursa) which requires fluid aspiration and analysis. Imaging: Not required. Ultrasound if concern for synovitis. Treatment: If traumatic, compression with elbow pad, ice for swelling, NSAIDs for pain. Antibiotics for infection. Ulnar Collateral Ligament (UCL) Tear Common in throwers, wrestlers, gymnasts and football players. History of valgus stress on outstretched arm. Physical exam: Valgus stress w/ 30 degrees flexion pain and instability Imaging: MRI with contrast arthrography Treatment: Conservative: ice and NSAIDs. Activity modification (e.g. no throwing) for approximately 6 months. Surgery: Reconstruction of UCL (Tommy John surgery) Ulnar Nerve Entrapment History: Paresthesias of the ulnar 1½ digits and ulnar dorsal hand. Physical exam: Symptoms reproduced with tapping (tinel sign), cubital tunnel compression and/or elbow hyperflexion. Weakness of fingers and interosseus muscle atrophy may be appreciated in late stages. Check for ulnar nerve subluxation with flexion/extension. Caution: Perform neck exam to rule out C8 pathology. Ulnar nerve entrapment may also accompany UCL strain/tear, so be sure to test for valgus instability and pain with valgus stress. Treatment: activity modification, night splint (relative elbow extension), NSAIDs. Surgery for refractory cases. Biceps Tendon Rupture Rupture of distal biceps tendon which attaches to radial tubercle. History: Forceful lifting or supination followed by sudden pain deep in the antecubital fossa. Physical exam: Tenderness to palpation of radial tubercle and antecubital fossa. Pain/weakness with flexion/supination. Imaging: Ultrasound. Treatment: Surgical reattachment of tendon.

15 Posterior Elbow Dislocation History: Fall/twisting injury to elbow. Physical exam: Olecranon prominent posteriorly. Imaging: Radiograph to rule out associated fracture Treatment: Stabilize the arm. Reduction should only be performed by experienced practitioner. Immobilization <3 wks. F/u with physical therapy. Complications: ulnar n. injury > median n. injury, brachial a. injury is rare. Perform careful neurovascular exam. Brief Notes on Elbow Fractures: Radial Head/Neck fracture: Commonly occurs after fall. May be occult (posterior fat pad sign on radiograph). Causes elbow stiffness if not mobilized quickly. Olecranon fracture: Common in elderly patient after fall Medial epicondyle avulsion fracture: Throwing injury common among pediatric patients. (May endorse popping sensation at time of injury.) Back to Table of Contents

16 WRIST/HAND Scaphoid Fracture History: Radial wrist pain after forward fall onto outstretched pronated hand. Physical exam: Snuffbox tenderness indicates scaphoid fracture until proven otherwise! (see picture) Swelling, decreased range of motion, or pain with resisted supination may be present. Imaging: Plain radiographs including lateral, oblique, and scaphoid views. Up to 30% of the radiographs may be nondiagnostic. Treatment: Immobilize hand/wrist and repeat films in 2 weeks if radiographs are non-diagnostic. If radiograph shows fracture, then thumb spica cast for 6-10 weeks. Refer to surgeon if scaphoid is displaced > 1 mm.

17 Distal Radius Fracture History: Athletic injuries in young people. If -> 50 years old, then could have fallen onto outstretched hand. Physical exam: Tenderness to palpation of distal radius. Swelling. Deformity indicates displacement. Palpate for ulnar tenderness and snuffbox tenderness as well. Caution: Acute carpal tunnel syndrome (acutely worsening median nerve dysfunction) on exam indicates that compartment syndrome is developing and is a surgical emergency! Imaging: Plain radiographs including lateral and oblique. Treatment: Reduction and cast immobilization if there is minor displacement. Refer to surgeon if open fracture, neuro or vascular complications, unstable fracture (e.g., fracture with dislocation). Triangular Fibrocartilage Complex (TFCC) Tear/Sprain TFCC: Triangular fibrocartilage discus + radioulnar ligaments (stabilizes distal radial and ulnar joints) + ulnocarpal ligament History: Patient fell onto outstretched hand and twisted wrist. Ulnar sided wrist pain. Physical exam: Ulnar-sided pain with forced ulnar deviation, wrist extension, and resisted pronation or supination. Imaging: Plain radiographs to rule out ulnar styloid fracture and ulnar variance. MRI and arthrography if tear is suspected. Treatment: TFCC sprain: Splint for 4 weeks with ice and NSAIDs. Consider ortho referral if no improvement. TFCC tear: Refer to ortho.

18 Carpal Tunnel Syndrome The carpal tunnel contains the median nerve, flexor pollicis longus tendon, flexor digitorum superficialis, flexor digitorum profundus. Increased pressure in carpal tunnel can cause nerve damage. History: Patient feels numbness or parasthesias on volar surface of radial 3.5 fingers. Physical exam: May have positive Tinel and Phalen signs. If in later stage, patient will have decreased sensation of light touch and vibration, pain and temp are preserved longer. Treatment: Activity modification, night splinting, NSAIDs. Consider corticosteroid injection for short-term relief. Surgical referral if chronic problem and no relief with multiple corticosteroid injections. De Quervain s Tenosynovitis Tendon entrapment of abductor pollicis longus and extensor pollicis brevis under radial styloid. May present similarly to carpometacarpal osteoarthritis. History: Overuse injury caused by gripping. Pain in radial volar aspect of wrist with pinching or use of the wrist. Pain with extension/abduction of thumb. Physical exam: Pain with resisted thumb abduction and extension. Positive Finklestein maneuver. Imaging: Radiograph to rule out other etiology (e.g., OA), but not necessary for diagnosis. Treatment: Ice and NSAIDs. Use thumb spica splint to restrict movement (particularly thumb abduction and extension). Perform stretching exercises. Glucocorticoid injections if needed. Refer to surgery if no improvement after 2 glucocorticoid injections and 1 year. Carpometacarpal Osteoarthritis (CMC OA) History: Insidious onset of pain in CMC. Patient exhibits pain with pinching or gripping and may feel that the thumb is weak. Physical exam: Palpate for tenderness on volar side of joint. Pain with axial compression and movement of thumb. Crepitus. Decreased strength and range of motion. Imaging: Plain radiographs, but not required for diagnosis Treatment: Analgesic therapy (acetaminophen, NSAIDs, etc.), May give glucocorticoid injections, capsaicin, or a glucosamine supplement. Definitive treatment is surgery.

19 Thumb Ulnar Collateral Ligament (UCL) Sprain/Tear (Gamekeeper s Thumb or Skier s Thumb) History: Hyperabduction or hyperextension of thumb. E.g., hit thumb on ski pole at high velocity. Physical exam: Palpate for tenderness over thenar eminence. Look for swelling or thumb displacement. May exhibit ligamentous laxity with valgus stress at thumb MCP. Imaging: Plain radiographs to rule out bony avulsion. Treatment: Casting. Complication: Stener lesion the aponeurosis of adductor pollicis goes between UCL and its insertion site, preventing healing. Requires surgical repair. Trigger Finger (Stenosing Flexor Tenosynovitis) Inflammation causes thickening flexor tendon which is then unable to glide smoothly through the retinacular pulley system. History: Patient complains of snapping and pain with flexion of affected finger, may lock in a flexed position. Physical exam: Tenderness of MCP joint on volar side of hand, directly over affected tendon. Look for pain with resisted flexion or passive extension. Imaging: None indicated. Treatment: Immobilize affected finger(s) with buddy taping or finger splint for 4-6 weeks. Ice as needed for pain. Give glucocorticoid injections for severe cases. Surgery: Refer to surgeon after failure of 2 glucocorticoid injections and perform trigger finger release.

20 Mallet Finger Extensor tendon injury of DIP. History: Direct axial blow to fingertip (e.g, basketball, or a hard surface). Pain over dorsal DIP with inability to straighten finger. Physical exam: Swelling and ecchymosis (if acute). Flexion of DIP at rest. Dorsal DIP tender to palpation. Limited active extension of affected finger. Usually full passive range of motion. Imaging: Plain radiographs including A/P, lateral, and oblique to evaluate for fracture and/or misalignment of finger. Treatment: If no subluxation, splint DIP joint in extension for 6-8 weeks Refer to ortho if complicated (e.g., limited passive range of motion, subluxation, or full laceration of tendon. Dorsal PIP Dislocation History: Hyperextension of finger, acute onset pain, and inability to move finger. Physical Exam: Swelling and deformity present on inspection. Impaired active and passive range of motion. Imaging: Plain radiographs including A/P, true lateral, and oblique to rule out fracture. Repeat radiographs after reduction. Treatment: Reduce if simple dislocation (single joint, no fracture, non-open joint with intact neurovascular function). Splint for 3-5 days with buddy tape to adjacent finger. Perform range of motion exercises. Consult orthopedics if complicated. Back to Table of Contents

21 Hand/Wrist Special Test Glossary Tinel: Tapping lightly over volar aspect of wrist reproduces paresthesias. Return to Carpal Tunnel Syndrome Phalen maneuver: placing dorsum of hands together for 30 sec-1min reproduces paresthesias via compression of carpal tunnel. Return to Carpal Tunnel Syndrome Finkelstein maneuver: Pain over radial styloid with passive ulnar deviation of fist with thumb adducted inside the fist. (Maximally stretching the affected tendons) Return to Table of Contents Return to De Quervain Tenosynovitis

22 HIP Hip Osteoarthritis History: Chronic anterior hip/groin pain, worse with movement and weight bearing Physical exam: Pain with limited flexion and internal rotation. DDx: Occult frx, osteonecrosis. Imaging: 1. plain radiograph. 2. MRI if diagnosis is unclear. Treatment: NSAIDs, activity modification. Definitive treatment is surgery. Femoral Fractures Intracapsular fracture predisposes to avascular necrosis due to poor blood supply. Femoral Neck Fracture (Intracapsular) High risk AVN. History: Fall onto lateral hip, twisting mechanism with foot planted (elderly). High intensity trauma, such as car accidents in young people. Acute onset of pain with movement, pain associated with weight bearing. Physical exam: If displaced, leg may be externally rotated and shortened. Swelling and ecchymosis may be absent. Imaging: Radiographs including AP view with maximum internal rotation and lateral view. If high suspicion, keep patient non-weight bearing until MRI is obtained. Treatment: refer to orthopedic surgeon.

23 Intertrochanteric Fracture (Extracapsular) High risk of displacement. Low risk of AVN. History: Pain after fall in elderly person. Physical exam: Swelling and ecchymosis often present. Leg may be shortened and externally rotated (if displaced). Local tenderness to palpation. Caution: Risk of blood loss into thigh because fracture is extracapsular. Monitor for hemodynamic stability. Imaging: See above. Treatment: Consult orthopedics. Usually requires surgical fixation. Avascular Necrosis (AVN or Osteonecrosis) of Femoral Head Necrosis of bone trabeculae and marrow that may result in collapse of bone. Thought to be secondary to impaired bone vasculature, although etiology is often unclear. Risk factors: high EtOH intake, high dose or long term corticosteroids, and trauma mean age <40 y/o History: Groin pain with movement and weight bearing. ⅔ of patients have pain at rest, and ⅓ have pain at night. +/- thigh or buttock pain. Physical exam: Similar to osteoarthritis. Non-specific. Pain with flexion and internal rotation Imaging: AP and frog leg lateral radiograph (not sensitive for early AVN). MRI is the gold standard. Treatment: Treatment is controversial. Goal is to preserve native joint. Treatment options vary depending on symptoms and extent of disease. 1. non-operative: includes bisphosphonates, vasodilators, anticoagulants and statins. 2. joint-preserving surgery 3. total hip replacement

24 Greater Trochanteric Pain Syndrome (Trochanteric Bursitis, IT Band Syndrome, Gluteus Medius Tendinopathy) Greater trochanter is insertion point for gluteus medius & minimus, piriformis, superior gemellus, obturator externus and obturator internus. Greater trochanteric pain syndrome refers to lateral hip pain caused by gluteus medius or minimus tendinopathy, IT band syndrome (+/- snapping hip), piriformis tendinopathy, or trochanteric bursitis. History: Lateral hip pain over greater trochanter, worse with pressure (lying on the affected side) and with standing on affected leg. Physical exam: Tenderness to palpation of greater trochanter. Pain with resisted abduction and external rotation. Trendelenburg sign may be present if gluteus medius tear exists but otherwise, full active and passive ROM and full strength. Imaging: MRI = gold standard. Ultrasound can assess tendons and bursae. Treatment: rest, ice, NSAIDs. Steroid injection or lidocaine. Physical therapy and activity modification. Surgery only for refractory cases. Femoroacetabular Impingement (FAI) Damage to acetabulum and femoral neck due to abnormal contact between the two structures. Most common in young adults. Predisposes to early hip arthritis. 2 types of impingement, often seen in combination: Cam impingement: abnormal femoral head-neck contour (femoral neck is wide) Pincer impingement: (overcoverage) acetabulum is too deep

25 History: insidious onset hip/groin pain, similar to OA but in young adults. Physical exam: Pain with passive flexion, adduction, and internal rotation at the hip. Imaging: Plain radiographs. MRI (hip series) and MR arthrography (allows for evaluation of labrum and acetabular rim). Treatment: Surgery aims to recreate normal anatomy, increase range of motion, and decrease femoral abutment of acetabular rim. Hip Flexor Strain Stretching or tearing of 1 or more of the hip flexor muscles. Commonly seen in runners, football kickers, & soccer players. History: sharp or pulling pain in anterior hip/groin. Often occurs during sprinting or forceful kicking, and pain with walking up stairs. Physical exam: Anterior groin TTP. Pain with hip flexion against resistance. Imaging: Radiograph to rule out avulsion fracture. U/S or MRI to evaluate severity of strain. Treatment: RICE, NSAIDs, PT. Internal Snapping Hip Syndrome (Iliopsoas Tendonopathy) (Internal Coxa Saltans) Transient subluxation of iliopsoas tendon over pelvic brim or anterior aspect of femoral head. May be associated with iliopsoas tendinitis. Common in athletes with extreme hip ROM (e.g., ballerinas).

26 History: Painful snapping with hip extension from flexion, e.g., pain with running, standing up from seated position. Physical exam: audible popping with pain anteriorly during hip extension and internal rotation from a flexed and externally rotated position. Imaging: Dynamic ultrasound and/or MRI. Treatment: Activity modification, NSAIDs, stretching. Surgical lengthening or release is indicated for refractory cases. Caution: Intraarticular DDx includes labral tear, cartilage defects, loose bodies, fracture fragments. Intraarticular pain often described as catching or sharp/stabbing. Note: Pelvic fractures are not covered, but in case of trauma (e.g., high fall or car crash), suspicion for pelvic fracture must be high as it can lead to hemodynamic instability and death. Back to Table of Contents

27 KNEE Osteoarthritis Degeneration of articular cartilage. 3 compartments: medial, patellofemoral, lateral. Risks: >50 y/o, obesity. History: Chronic aching pain, insidious onset, worse with weight bearing. Physical exam: crepitus, bony tenderness and enlargement. No warmth. +/- small effusion. Imaging: Plain weight-bearing radiographs, include sunrise view (patellofemoral compartment) Treatment: Analgesics, rest, PT. Long term: total knee replacement surgery. Anterior Cruciate Ligament (ACL) Tear History: Non-contact pivoting injury, may have heard an audible pop. Physical exam: Positive Lachman test, Anterior drawer test. Swelling from hemarthrosis is common. Imaging: Plain radiograph followed by MRI Treatment: PT mobilization; do not immobilize. Surgical repair. Note: Associated meniscal tear is common.

28 Medial Collateral Ligament (MCL) Tear History: Valgus force to knee (e.g., direct blow from outside). Physical exam: Pain and instability with valgus stress at 30 degrees flexion. Imaging: MRI. Treatment: hinged knee brace. Posterior Cruciate Ligament (PCL) Tear History: Blow to anterior tibia w/ flexed knee (dashboard injury), fall onto ground w/ plantarflexed foot. Physical exam: Posterior drawer. Imaging: Plain radiographs to eval for avulsion injury, stress radiographs, MRI. Treatment: Depends on degree of injury. Some may be managed non-operatively w/ rehab focused on knee extensor strengthening. PCL surgical reconstruction if combined injury or complete tear with instability. Lateral Collateral Ligament (LCL) Tear LCL is weakest of knee ligaments, but injury is uncommon due to mechanism. History: Varus stress followed by pain. Physical exam: Lateral joint line ttp. Pain and instability with varus stress at 30 degrees flexion. Imaging: Consider AP, lateral, varus stress radiographs. May consider MRI if question of additional injury. Treatment: Rehab/brace.

29 Meniscal Tear History: Young patients: twisted knee while flexed with foot planted on the ground. +/- popping sound. Older patients: degenerative tear, may not have h/o trauma. Stiffness. Sensation of knee catching/locking. Pain exacerbated by twisting. May perceive inappropriate knee position or that knee isn t moving properly. Physical exam: Depending on type of tear, exam may be normal. Effusion common. Medial or lateral joint line tenderness to palpation. Positive McMurray test. Abnormal range of motion with inability to fully extend knee. Imaging: Radiographs- sunrise, tunnel, PA, lateral. MRI to characterize extent of tear if considering surgery. Treatment: If no swelling, catching, locking or giving way then treat conservatively with PT to strengthen quads and hamstrings, rest, ice and crutches. Refer to orthopedic surgeon if large effusion, disabling symptoms or poor response to conservative therapy. Patellar Dislocation Commonly a lateral displacement of patella from trochlear groove. May be confused with ACL tear at presentation due to history of loud pop and immediate swelling. History: Foot planted, internal rotation of knee with valgus force. Pt may endorse hearing loud pop/tear, knee giving out, and severe pain. Physical exam: limited range of motion due to swelling/hemarthrosis. Patella may be palpated laterally. Medial edge of patella and medial femoral condyle tender to palpation. Imaging: AP, lateral, sunrise view radiographs (evaluate after reduction) Treatment: Reduction followed by RICE, NSAIDs, brace. Start rehab after 2-3 days to encourage mobility. Patellofemoral Pain Syndrome Overuse injury leading to acute or chronic knee pain. May be due to sudden overload/increase in activity, imbalance of quadricep muscles, or malalignment of patella in trochlear groove.

30 History: Pain under or around the patella, poorly localized. Theatre sign hurts when patient stands up after sitting for long period. Worse with squatting, running, ascending or descending stairs. Review exercise history (recent increase in intensity). Physical exam: Positive patellofemoral compression test, patella facet retinaculum tenderness. Imaging: Not indicated unless concern for patellofemoral instability or OA. PFPS is a clinical Dx. Treatment: NSAIDs, ice, activity modification, PTquadriceps strengthening, rehab, orthotics, bracing. Iliotibial Band (ITB) Syndrome ITB anatomy: iliac crest to proximal tibia. Courses over lateral femoral epicondyle, proximal to joint line. Overuse injury, previously thought to be due to friction between ITB and femoral epicondyle. Exact etiology is unknown. Common in runners History: Sharp or burning lateral knee pain before/during foot strike of running or during downward pedal force on bike Physical exam: ITB tender over lateral femoral tubercle. Positive Noble test. Positive Ober s test. Imaging: none required. +/- ultrasound Treatment: Rest, ice, NSAIDs followed by PT for strength and mobility, rehab Patellar Tendinopathy (Jumper s Knee) History: Anterior knee pain. Worse with running, jumping, squatting. Physical exam: Patellar tendon tender to palpation. May be enlarged compared to non-affected side. Full knee range of motion. Imaging: Ultrasound to assess for tendinopathy +/- partial tears. Treatment: activity modification, PT, stretching, ice, NSAIDs (short term).

31 Prepatellar Bursitis Bursa is located between patella and overlying skin History: 2 mechanisms: Direct blow or a fall onto the knee. Bleeding into bursa causes inflammatory reaction-->bursitis. Would likely see bruising. Chronic use from people who work on their knees (carpet layers & plumbers). Physical exam: Effusion over the patella. Patella tender to palpation. Pain at patella with knee flexion. If skin is hot, red, or exquisitely tender, bursa may be infected. Imaging; Radiograph if history concerning for patellar fracture. Treatment: -May aspirate fluid if hindering recovery and analyze for infection. Antibiotics prn infection. Ice. PT if limited ROM. Refractory cases may warrant surgery. Popliteal (Baker s) Cyst Soft, painless cyst in the popliteal fossa (swelling of gastrocnemius-semimembranous bursa). Usually an incidental finding (on imaging) secondary to either OA or meniscal tear which can both cause synovial fluid to leak from the joint capsule, forming a cyst. History: Usually painless. Patient may complain of swelling, stiffness, discomfort with standing for long periods. Physical exam: Often not appreciable on exam. If large cyst: swelling posteriorly. If cyst dissects, lower leg may appear swollen, red, and tender (much like DVT!). Imaging: Usually not indicated. Ultrasound to rule out solid mass, aneurysm, or DVT. Treatment: Treat underlying joint disorder. If symptomatic, corticosteroid injections. Back to Table of Contents

32 Knee Special Test Glossary: Lachman s test: Used to diagnose ACL injury. Patient supine with affected knee flexed at degrees. Examiner places 1 hand behind tibia & other hand on patient s thigh then pulls the tibia forward to assess laxity. If significant laxity is demonstrated, this is a positive test. Return to ACL Tear Anterior drawer: Used to diagnose ACL injury. Patient supine with the affected knee bent at 90 and foot flat on the table. Gently sit on the patient s foot to prevent movement and grasp the patient s affected knee with your hands and pull the shin bone forward while assessing for laxity. If significant laxity is demonstrated, this is a positive test. Repeat on the other knee for comparison. Return to ACL Tear Posterior drawer: Used to diagnose PCL injury. Patient supine with the affected knee bent at 90 and foot flat on the table. Gently sit on the patient s foot to prevent movement and grasp the patient s affected knee with your hands and push the shin bone posteriorly, assessing for laxity. If significant laxity is demonstrated, this is a positive test. Repeat on the other knee for comparison. Return to PCL Tear. McMurray s test: Used to diagnose meniscal tears. Patient supine. Start with knee maximally flexed. Apply valgus force to the knee, while at the same time externally rotating and extending the knee completely. Then place the affected leg back in the maximal hip and knee flexion. While palpating the joint line, apply a varus force to the knee, while at the same time internally rotating and extending the knee completely. Pain or clicking is a positive result. Return to Meniscal Tear. Patellofemoral compression test: pain when patella is pressed straight down into trochlear groove with leg extended. Return to Patellofemoral Pain Syndrome Patella facet retinaculum tenderness: With leg relaxed, displace patella laterally or medially and palpate in facet and underside of patella to evaluate for tenderness. Return to Patellofemoral Pain Syndrome Noble s test: With patient lying in lateral decubitus position, passively flex patient s affected limb s hip and knee to 90 degrees. Apply pressure with your thumb over the IT Bank proximal to the lateral femoral condyle. Have the patient actively extend his/her hip and knee. Pain before 30 short of knee extension is a positive sign. Return to ITB Syndrome Ober s test: With patient lying in lateral decubitus position on unaffected side, with bottom hip and knees flexed to approximately 90 degrees for stability. Passively abduct and extend the hip of the affected leg. Allow the leg to then adduct, still extended (lowering the table behind the patient s unaffected leg). Test is positive if the leg will not adduct past neutral position, indicating tightness of ITB or tensor fasciae latae. Return to ITB Syndrome Return to Table of Contents.

33 ANKLE Ankle Sprains Lateral Sprain Most common (85%). Anterior talofibular ligament (ATFL) is affected first. History: Rolled ankle (inversion), may hear popping noise at time of injury. Pain with weight bearing. Physical exam: Swelling distal to lateral malleolus. If ATFL full tear, positive Anterior drawer. If posterior talofibular (TFL) tear, positive Talar tilt. Imaging: AP, lateral, ankle mortise radiographs indicated to evaluate for fracture if Ottowa ankle criteria are met. Treatment: Stabilize ankle with brace, mobilize when tolerable, RICE, NSAIDs, PT/rehab. Refer to orthopedic surgeon if tendon rupture, fracture, dislocation or subluxation. Medial Sprain History: Medial pain after eversion of foot. Uncommon. Physical exam: swelling distal to medial malleolus. Imaging: AP, lateral, ankle mortise radiographs indicated to evaluate for fracture only if Ottowa ankle criteria are met. Treatment: Stabilize ankle with brace, mobilize when tolerable, RICE, NSAIDs, PT/rehab. Refer to orthopedic surgeon if tendon rupture, fracture, dislocation or subluxation. High Ankle Sprain (Syndesmotic)

34 Syndesmotic ligament connects tibia to fibula. Sprain usually due to force of excessive external rotation on fibula. Common in skiing/hockey (due to stiff boots) or high impact sports. Recover time is twice as long as LCL sprains. Physical exam: proximal ankle swelling. Pain with external rotation. Positive squeeze test. Imaging: AP, lateral, ankle mortise radiographs indicated to evaluate for fracture if Ottowa ankle criteria are met. Treatment: Stabilize ankle with brace, mobilize when tolerable, RICE, NSAIDs, PT/rehab. Refer to orthopedic surgeon if tendon rupture, syndesmotic injury (high ankle sprain), fracture, dislocation or subluxation. Osteochondral Defect (aka Osteochondritis Dessicans) History: Patient experiences chronic worsening pain after inversion ankle injury (ankle sprain) often with associated clicking, stiffness, and weakness. Physical exam: Look for swelling with or without effusion. Palpate for tenderness over talar dome while plantar-flexing and dorsi-flexing the ankle. Imaging: Plain radiographs including oblique, mortise, and plantar-flexed views. Consider MRI if symptoms persist and radiographs are normal. Treatment: Rest, immobilization, NSAIDs, and physical therapy. Refer to orthopedics. Distal Fibular Fracture Ankle joint includes tibia, fibula and talus. History: Patient twisted or rolled his/her ankle, or trauma such as car accident. Worse with weight bearing. Physical exam: Look for swelling and tenderness to palpation at ankle. Imaging: See Ottowa ankle rules. Plain radiograph. +/- MRI. Treatment: RICE, NSAIDs, physical therapy, and bracing. Surgery if ankle is unstable. Note: Dislocation can also occur with ankle fracture, most commonly with bimalleolar or trimalleolar fractures (fractures involving 2 or 3 ankle bones). Posterior Tibial Tendinopathy

35 Posterior tibial tendon courses behind the medial malleolus and into plantar surface of foot. Helps support the arch of the foot. History: Pain on the medial aspect of the foot and posterior medial malleolus. Physical exam: Tenderness along course of posterior tibial tendon. +/- swelling. If tendon is ruptured, inspect for flatfoot deformity. Imaging: MRI if tendon rupture is suspected. Treatment: Orthotics for arch support. Rest foot. NSAIDs. Consider referral for chronic tendinopathy if no improvement with orthotics. Refer to orthopedics if tendon rupture is suspected, or confirmed by imaging. Peroneal Tendinopathy Peroneus longus & peroneus brevis course behind the lateral malleolus. Peroneal tendons contribute to plantar flexion and eversion of the foot.

36 Peroneal tendinopathy may be secondary to ankle sprain, or due to chronic repetitive ankle use (e.g., running and jumping). History: Pain in outer part of ankle or behind lateral malleolus. Physical exam: Palpate posterior to lateral malleolus and along course of tendon for tenderness. Imaging: Plain radiographs to rule out fracture. Treatment: Immobilize foot & lower leg in a short-leg walking boot for 2-4 weeks. Stretch, RICE, physical therapy, and NSAIDs. Return to Table of Contents

37 Ankle Special Test Glossary Anterior drawer: With patient sitting, stabilize distal tibia with one hand and apply anterior force to the heel of the foot, assessing for ligamentous laxity (lack of an end point). Compare to unaffected side. Return to Ankle Sprain Talar tilt: with patient seated and foot in degrees of plantarflexion (foot relaxed and unsupported), support medial aspect of lower leg with one hand, while holding the heel with the other hand and inverting the foot. Assess for laxity with inversion. Increased laxity is suggestive of ATFL and calcaneofibular ligament injury. Return to Ankle Sprain Squeeze test: Squeezing tibia and fibula together at level of the mid-calf produces pain distally near the ankle because compressing the tibia and fibula proximally causes stretching of the syndesmosis distally. Return to Ankle Sprain Ottawa ankle rules: Indication for x-ray in patient presenting with ankle pain: Ankle pain AND at least one of the following: 1. Tenderness to palpation of posterior malleolus or 6cm of posterior edge of distal fibula 2. inability to bear weight immediately after injury and for 4 steps in ER 3. navicular tenderness to palpation 4. 5 th metatarsal tenderness to palpation Return to Ankle Sprain Return to Jones Fracture Return to Table of Contents

38 FOOT Hallux Rigidus Degenerative arthritis of first metatarsophalangeal (MTP) joint (at the base of first toe). History: Patient can t move big toe and pain felt usually before toe-off when walking. Pain intensifies with high heels. Physical exam: Palpate MTP for bony enlargement and tenderness. Imaging: Plain radiographs. Treatment: Symptom management with orthotics, rocker type of sole, and NSAIDs. Cortisone injections. Surgical options for severe symptoms. Hallux Valgus (Bunion) History: Patient feels pain on medial aspect of first toe. Wearing pointed tight shoes can worsen deformity. Physical exam: Valgus deformity on inspection. Medial MTP may be tender to palpation. Imaging: Plain radiographs to measure angles of bones. Treatment: Orthotics to have a wide shoe to remove pressure and physical therapy usually for 4-6 sessions. Bunionectomy for refractory cases. Jones Fracture Fracture of diaphysis of 5th metatarsal. High risk of non-union due to poor blood supply. May present similarly to sprain, but need high index of suspicion for fracture (Ottowa criteria for radiograph).

39 History: Pain with difficulty walking as well as swelling, often after inversion injury. Physical Exam: Inspect for swelling. Palpate dorsal foot and proximal 5 th metatarsal (bony prominence). Imaging: Plain radiographs. Treatment: Cast, splint, or walking boot for 4-8 weeks and NSAIDs. If non-union, refer to orthopedics. Lis-Franc Injury Fracture of bones in midfoot or torn ligament of midfoot. There is no connective tissue holding 1st metatarsal to 2nd metatarsal so a twist can dislocate the bones. History: Dorsal foot pain after twisting injury. Pain worse with weight bearing. Physical exam: Swelling and bruising on dorsal aspect of foot. Bruising may be present on plantar side of foot. Palpate along midfoot for tenderness. Imaging: Plain radiographs to rule out fracture. MRI to evaluate soft tissue damage. Treatment: Non-weight bearing cast for 6 weeks (do not put any weight on it!) and physical therapy/rehab. Some fractures may require surgery. Stress Fractures Fracture due to overuse. Commonly distance running, tennis, gymnastics, dance, basketball. 2 nd and 3 rd metatarsals most common. Calcaneous, fibula, and navicular are also common. Must consider osteoporosis in elderly patients. Consider female athlete triad in young women.

40 History: Insidious onset of pain. Pain increases with weight bearing activities, diminishes with rest. Swelling at top of foot or outside ankle. Physical Exam: Localized tenderness to palpation at site of fracture. Imaging: Plain radiographs Treatment: NSAIDs and RICE. Midfoot Arthritis May be result of acute injury or chronic process. History: Burning, tingling, & pain in dorsal foot. Stiffness of foot. Physical exam: Decreased ROM of foot and ankle. Assess gait. Imaging: Plain radiographs to rule out stress fracture. Treatment: Treat with NSAIDs, orthotics, and activity modification. Brace ankle. If patient has a stress fracture, treat with casting and rest. Morton s Neuroma Thickening of nerve sheath of digital nerve supplying toes, most commonly between 3rd and 4th toes. Women > men. History: Burning pain in ball of foot that (may) radiate to the toes. +/- Numbness of toes. Physical exam: Palpate for mass and listen for clicking with movement. Imaging: Plain radiographs to rule out stress fracture or arthritis. Treatment: Orthotics - shoe inserts, change the type of shoe the patient wears, and may give corticosteroid injection. Return to Table of Contents

41 BACK/SPINE This study guide will not cover different types of MSK back pain or management of back pain but will touch briefly on back pain red flags. For a patient presenting with low back pain, the DDx must include: 1. Musculoskeletal 2. Malignancy (bony metastases) 3. Infection (epidural abscess, osteomyelitis) 4. Systemic disease (ankylosing spondylitis, Reiters, IBD, etc.) 5. Visceral pain (AAA, pelvic, GI, renal) Most musculoskeletal back injuries improve without treatment over 4-6 wks. A patient with the following red flags may warrant further workup and imaging immediately: Traumatic mechanism of injury o Elderly, fall from standing o Younger patient fall from high distance History of weight loss, night sweats, malignancy malignancy History of IV drug use, bacterial endocarditis, or osteomyelitis infection Point tenderness to palpation on vertebrae (as opposed to muscle) infection or malignancy Neurological symptoms concerning for cauda equina syndrome (surgical emergency!) o Bowel or bladder incontinence o Saddle anesthesia o Bilateral leg weakness, numbness or paresthesias o Decreased rectal tone Acute onset of neurologic deficit or progressive worsening deficit suggestive of spinal cord compression Pain lasting >6 wks may require further workup/mri and surgery Back to Table of Contents