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Copy of Prezi español
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Caused by multiple factors
Not considered a consequence of aging anymore
Types of OA
Major cause of
Treatment includes medications, weight loss, rest and physical therapy
Diagnosis: xrays, labs, pe, symptoms
OA,Patellofemoral pain syndrome (chondromalacia patellae, bursitis, trauma; ligamentous sprains (meniscal, ACL/PCL/LCL), gout, Popliteal cyst (Baker's cyst), Inflammatory arthropathy (RA, Reiter's), Septic Arthritis
Can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination
Younger than 40 years history of dislocation or subluxation event
Positive apprehension and relocation are consistent with the diagnosis
Older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion.
Acromioclavicular osteoarthritis is usually well localized. A history of an injury (shoulder separation), heavy weight lifting, and tenderness to palpation at the acromioclavicular joint
MRI/US preferred for Rotator Cuff Disorders
Xray for shoulder instability and acromioclavicular and glenohumeral
Numbness, tingling, pain radiating past elbow =
Most ankle sprains are inversion injuries to the lateral ankle ligaments
Physical examination of the ankle includes inspection, palpation, determination of weightbearing ability, and injury-specific physical diagnostic tests.
Mild stretching with microscopic tears
Incomplete tear of ligament
One of the most common causes of foot pain in adults
(Etiology poorly understood)
A common complaint
1st line is Acetaminophen, then
Evaluation entails a
Rapid or insidious onset? Disnguish between inflammatory process
Continue activity, able to bear weight; did they hear a sound at time of injury, mechanism of injury, swelling (oldcarts)
Mensical Tear-Sudden twisting or pivoting
Locking episodes, mild to moderate swelling, recurrent knee effusion with acitivity, + McMurry's Test
Cruciate Ligamentous Injury
"Popping" at injury, episodes of knee giving way, instability, large effusion if ruptured of rapid onset, direct anterior force to knee, can occure from quick stops and sharp cuts or turns
+ Anterior Drawer/Lachman Test
Direct lateral blow medial collateral ligament injury
Medial blow lateral collateral ligament tear
Possible to have a combination of injuries
Acute Knee Pain
Rotator Cuff Pathology
Most often involve damage to the supraspinatus tendon. The supraspinatus muscle assists in abduction and external rotation of the shoulder. Tendinopathy, partial tears, and complete tears
pain with overhead activity, weakness on empty can
and external rotation tests, and a positive impingement sign.
Muscle atrophy, range of motion active and/or passive, strength
Again, a good history...
Chronic vs acute, progressive, injury, sports
Refer to Ortho
Again, a good history; most important
questions is whether or not the patient was able to bear weight after the injury
Tenderness of the distal tibia or fibula may represent a fracture
Swelling and eccymosis
Palpate the entire fibula
■Check for pain on gentle passive inversion and eversion of the ankle.
If there is no swelling or ecchymosis, and physical examination maneuvers do not elicit pain, no xray necessary
When to do xrays:
Crutches if necessary
Possible causes include:■Excessive training (particularly a sudden increase in the distance run)
■Faulty running shoes
■Running on unyielding surfaces
■Flat feet (pes planus or pronated ankles)
■Limited ankle dorsiflexion (eg, due to a shortened Achilles tendon)
■Pes cavus (high-arched) foot
However, there is no evidence to back any of these causes
Xrays are necessary to rule out
causes of pain, such as a calcaneal stress fracture
Rupture of the plantar fascia
Nerve pain due to entrapment
Tendinitis of the posterior tibialis or flexor digitorum longus tendons
Reactive arthritis and other
Painful heal pad syndrome
Avoidance of flat non supportive shoes, and walking barefoot
Arch supports, orthotics, heal cups
Causes persistent pain and dysfunction
Most common cause of shoulder pain
Main risk factor:
Repetitive activity at or above the shoulder during work or overhead sports (swimming, throwing, tennis, weightlifting, golf, volleyball, and gymnastics)
Instability of the glenohumeral joint
Combination of shoulder symptoms, examination findings, and radilogic signs attributable to the compression of structures around the glenohumeral joint that occur with shoulder elevation
The underlying mechanism of injury occurs when the rotator cuff, subacromial bursa, and other soft tissues (eg, long biceps tendon) are compressed between the humeral head and the undersurface of the acromion, acromioclavicular joint, or the coracoacromial arch
Patients complain of pain with overhead activity. The pain may localize to the deltoid area or lateral arm and often occurs at night or when lying on the affected shoulder
Edema and hemorrhage
patient generally <25 years
: Fibrosis and tendinitis
patient 25 to 40 years, current term is tendinopathy.
: Rotator cuff (RC) tear, biceps tendon rupture, bony change (patient generally >40 years
6. A 48-yo female presents
with this finding present for
1 month. No trauma or pain.
Your next best course of action
A. Obtain a needle biopsy of the lesion
C. Obtain further imaging
D. Provide her with a thumb spica splint
Pathologic analysis shows edema and thickening of vessel walls fibrosis, myelin thinning, and nerve fiber degeneration and regeneration
Compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesias, and less commonly, weakness in the median nerve distribution
The lowest CTP is seen in a neutral or slightly flexed position, and it increases proportionately with deviation from this posture
Associated with pregnancy, diabetes, and thyroid disorders
What is the best test for diagnosing CT?
Wrist splints, ultrasound, yoga, carpal bone
mobilization – possibly beneficial in short term
Corticosteroid injection – beneficial at 1 & 4 mo,
superior to oral corticosteroids
Surgical release – beneficial over splinting at 6
Surgical release to prevent progression of
symptoms as opposed to “return to
normal” Cochrane 2009
Connective tissue diseases
Preexisting median mononeuropathy
Aromatase inhibitor use
• Recommended treatment includes aspiration &
corticosteroid injection (x2) then surgical excision if necessary
**Cohort of 155 pt’s, >40% returned after aspiration or excision, 53% spontaneously resolved
Dorsal radial wrist most common
Thought to arise due to herniation of synovial tissue from a joint capsule or tendon sheath
The role, if any, of repetitive movement in causation is uncertain; it may induce enlargement of the lesion and may provoke symptoms
The lateral epicondyle of the elbow is the bony origin for wrist extensors
The medial epicondyle is the bony origin for wrist flexors
Factors that correlate with a poorer prognosis include high physical strain at work, dominant side involvement, concomitant neck pain (with or without signs of nerve root involvement), duration of symptoms greater than three months, and severe pain at presentation
A chronic tendinosis (chronic degeneration without inflammation)
Smoking, obesity, age 45 to 54, repetitive movement for at least two hours daily, and forceful activity (managing physical loads over 20 kg)
(X rays to r/o other pathology)
Physical Therapy and Eccentric Exercises
Can consider x rays if no improvement despite the above treatment
Inflammation of degeneration of the sac-like structures that protect the soft tissues from underlying bony prominences.
May result from a local insult or be a manifestation of a systemic disease (R/A, gout, sepsis)
Pain on motion and rest
Swelling is noticeable when it is close to the body surface
Local tenderness where the bursa is located.
History should include acute trauma or repetitive injury, occupation and vocational activities. Past medical history to r/o other causes; recent bacterial infection or fever to r/o infection.
Diagnostic testing to r/o other diseases (x ray), Bursal fluid aspiration,
Treatment includes avoiding direct pressure on the bursa, kneeling pads; NSAIDS, Indomethacin is first line, or Naprosyn, Glucocorticoid injection
Prepatellar bursitis usually related to trauma "housemaids knee" but can result from infection or gout
Back pain is the second most common symptom-related reason for clinician visits in the United States
Causes significant morbidity which interferes with
work, lifestyle, and quality of life. Rarely a sign of serious illness
■In the 2002 US National Health Interview Survey (NHIS), with over 30,000 respondents, 26.4 percent reported experiencing back pain lasting at least a whole day in the prior three months
The total costs of low back pain in the United States exceed $100 billion per year
One US survey found that 72 percent of those who sought treatment for back pain gave up on exercising or sports-related activities. Sixty percent said they were unable to perform some daily activities, and 46 percent said they had given up sex because of their back condition
Smoking, obesity, older age, female gender, physically strenuous work, sedentary work, psychologically strenuous work, low educational attainment, Workers' Compensation insurance, job dissatisfaction and psychological factors such as somatization disorder, anxiety, and depression
Poor physical health in both men and women, and heavier weight in women, increased the risk of new back pain. The same study found that jobs involving lifting, pulling, or pushing objects of at least 25 pounds, and jobs involving prolonged periods of standing or walking, were associated with a higher incidence of low back pain, especially among women
■Is there evidence of systemic disease?
■Is there evidence of neurologic compromise?
■Is there social or psychological distress that may contribute to chronic, disabling pain
History, History, History
Suggestive of Systemic Disease
■History of cancer
■Age over 50 years
■Unexplained weight loss
■Duration of pain greater than one month
■Unresponsiveness to previous therapies
Other Red Flags
Prolonged use of corticosteroids, osteoporosis
Focal neurologic deficit (s) with progressive or disabling symptoms
Cauda Equina syndrom
Cauda equina syndrome
**Unnecessary imaging studies can expose individuals to radiation without good reason. As an example, gonadal radiation from a two view lumbar spine radiograph is equivalent to radiation exposure from a chest radiograph obtained daily for more than one year
When and who to refer to?
Progressive or severe neurologic deficit
Patients may also be referred to a neurologist or physiatrist if any of the following are present:
Neuromotor deficit that persists after four to six weeks of conservative therapy
Persistent sciatica, sensory deficit, or reflex loss after four to six weeks in a patient with positive straight leg raising sign, consistent clinical findings, and favorable psychosocial circumstances (eg, realistic expectations and absence of depression, substance abuse or excessive somatization)
Neurosurgeon or othopedist that specializes in back surgery
Cauda Equina syndome
Suspected spinal cord compression
Most common causes include ligamentous muscular injury, degeneration (osteoarthritis or spondylolysis, and disc herniation
Evidence of nerve root irritation typically manifests as sciatica, a sharp or burning pain radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle.
Sciatic nerve pain is often associated with numbness or tingling. Sciatica due to disc herniation usually increases with coughing, sneezing, or performance of Valsalva maneuver
Nerve root entrapment caused by narrowing of the spinal canal (congenital or acquired), nerve root canals, or intervertebral foramina.
Caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum.
Symptoms include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest. "pseudoclaudication"
Compression of multiple lumbosacral nerve roots characterized by:
•low back pain
•unilateral or bilateral sciatica
•bladder and/or bowel dysfunction
•decreased perineal sensation
•possible neurologic findings in legs (motor loss, sensory changes, reflex changes)