For the following Musculoskeletal structure, give an example of characteristic Pathology

1.  Synovial Joints

2. Tendons

3. Entheses (insertion sites of tendons and ligaments into bones)

4. Soft tissues

1.  Synovial Joints=Arthritis

2. Tendons=Tendonitis

3. Entheses=Dactylitis

4. Soft tissues=Fasciitis

1. Localization of pain source if present

2. Tempo of disease

3. Pattern of joint involvement

4. Presence of systemic inflammatory symptoms

5. Extra-articular findings

JOINT SWELLING (tumor)

1. More or less specific than pain

2. More or less objective for joint inflammation as warmth and redness

1. More specific than pain

2. Less objective for joint inflammation as warmth and redness

JOINT WARMTH (Calor)

1. More or less specific than joint swelling?

JOINT PAIN (dolor)

1. Common or uncommon?

2. Easy or hard to objectively assess?

1. The most common symptom

2. Hard to objectively assess this complain, esp if dealing with actors

Loss of Function (Laese functio)

1. Accurate or innaccurate sign of inflammation?

1. THe most innacturate hippocratic sign of inflammation.  It is difficult to seperate true functional disability from motivational issues....

    a. Intentional: Malingering

    b. Psychological: Depression

MORNING STIFFNESS

1. What is typically associated with it (generally)

2. When lasting greater than 1 hour, what is it a typical sign of?

1. Active Inflammatory Disease

2. >1 hour is typical of Rheumatoid Arthritis

NUMBER OF JOINTS INVOLVED

1. How should disease presentation be described?

1. Single Joint Involvement (Monoarthritis, Monoarticular involvement)

2. Several Joints (Oligoarthritis)

3. Many Joints (Polyarthritis)

*Remember that a single disease can manifest in more than one way though

*Record these findings with joint homunculus

Symmetry of Joint Involvement

1. What is the classic disease that is symmetric?

2. Most other diseases are ??

1. RA

2. Asymmetric

*Use joint homunculus

SYMPTOM SEVERITY DURING THE DAY

1. What diseases are worse upon awakening with functional improvement throuhout the day (similar to morning stiffness)

2. What diseases tend to worsen over the day with usage?

1. Inflammatory Diseases

2. Non-Inflammatory diseases (ex: DJD)

CONSTITUTIONAL COMPLAINTS

1. Name a few that accompany systemic inflammation

1. Fever

2. Chills

3. Night Sweats

4. Myalgia

5. Weight Loss

6. Generalized Malaise

7. Fatigue

8. Asthenia

1) GI Function (diarrhea, esp with blood, anal fissuring, jaundice)

2) eye compaints

3) lung disorders (dyspnea)

4) Sexual habits, genital rash/lesions, discharge, inguinal adenopathy (STDS may PRODUCE (gonococcal arthritis) or TRIGGER (reactive arthritis) joint disease

ASSESMENT OF PERIARTICULAR WARMTH

1. How do you do it?

DEFORMITIES (represents? caused by?)

1. Ulnar Deviation

2. Swan Neck

3. Boutonniere

4. Digital Sublixation

5. Heberden's Node

6. Bouchard's Node

1. ULNAR DEVIATION: classic for Chronic RA, caused by tendon involvment with subsequent shortening

2. SWAN NECK: Represents inflammatory-related deformity (typical of ADVANCED RA) with flexion at the DIP joint and extension at PIP joint

3. BOUTONNIERE: Represents inflammatory-related deformity (typical of ADVANCED RA) with flexion at the PIP joint and extension at DIP joint

4. DIGITAL SUBLUXATION: another inflam-related finding typical of advanced RA.  Digits are pulled anterior to (in the anatomic position), or underneath the MCP joints.

5. HEBERDEN'S NODES: Bony prominence of DIP JOINTS.  Typical of DJD

6. BOUCHARD'S NODES: Bony prominence of PIP JOINTS.  Typical of DJD

6.

ENTHESOPATHY/ENTHESITIS

1. What is it?

2. What is a great example

1. inflamation of the enthesis (site of attachment of ligament, tendon, joint capsule, and or fascia TO BONE)

2. Typical ex: pain along the Achilles tendon or plantar pain (fasciitis)

DACTYLITIS (Sausage Digit)

1. What is it?

2. One disease it is characteristic of

3. 3 diseases it is rarely seen in

1. Related to enthesopathy, it is a difuse digital inflammation involving the flexor tendon, sheath, and soft tissues, distinctly different from pure synovial joint inflammation

2. Characterisitic of the Spondyloarthropathies

3. More rarely seen in...

a. TB

b. Syphillis

c. Sarcoid

AXIAL SKELETAL EXAM

1. Three things you should asses

2. One thing you should make sure to palpate

1. Extension, Flexion, lateral rotation of spine and neck

2. Palpate the sacro-iliac joints

SKIN EXAM

For the following inflammatory diseases, name the associated skin finding

1. SLE

2. Sceloderma

3. Dermatomyositis

4. RA

5. Gout

6. Septic Joint

7. Psoriasis

8. Reactive Arthritis (FOUR)

1. SLE: Malar & Discoid Rash

2. SCLERODERMA: Thickening, hyperpigmentation, sclerosis.

3. DERMATOMYOSITIS: Many specific findings

4. RA: Subcutaneous Nodules

5. GOUT: Urate Deposits in advanced disease

6. SEPTIC JOINT: Small painless skin lesions, ex, gonococcal arthritis

7. PSORIASIS: plaques

8. Reactive Arthritis:

 a. Hyperkeratotic lesions of palms/soles

b. Genital Lesions

 c. Oral Ulcers

 d. Conjunctivitis/Uveitis

NAIL PITTING

1. What is it?

2. What is it clue to?

1. Small pits in the fingernails

2. Clue to psoriasis and psoraitic arthritis (seen in 50% of pts with Psoriasis)

TESTS FOR CARPEL TUNNEL SYNDROME

1. Phalen's Test

2. Tinnel's Sign

1. PHALEN'S TEST: Have pt push dorsum of both hands together at 90 degrees to the forearms for 60 seconds.  This compresses the median nerves, and if the pt feels "tingling" over the nerve's distribution, it is considered +

2. TINEL'S SIGN: Percussion of wrist over median nerve (a + sign produces the same symptoms as Phalens)

LOVER'S ANKLE

1. What is it?

2. What is it seen in?

1. Achilles Tendon Inflammation (Tenosynovitis)

2. In setting of Disseminated Gonoccocal Infection

CHARCOT JOINT

1. What is produced by?

2. Originally recognized in ??, the most common cause currently is ??

1. Produced by Sensory deficit (eg neuropathy) of the involved joint.  Due to sensory deficit, the joint is subject is repeated painless trauma with ultimate destruction

2. Originally recognized in TERTIARY SYPHILLIS, the most common cause currently is DIABETIC NEUROPATHY (in Diabetes, the foot and ankle are most commonly involved)

DIGITAL ISCHEMIA

1. What should you check for (esp. in WHAT DISEASE?)

OSTEOARTHRITIS (aka Degenetive Joint Disease, DJD)

1. What is it caused by?

2. What is the result of the damage? (give two specific findings)

3. Inflammatory?

4. Distribution of involvement?

5. Typically involves what joints?

1. Caused by mechanical damage to joint cartilage (happens in anyone who lives long enough)

2. After the protective cartilage has worn off, bone on bone trauma creates pain, disability, and deformity (Heberden's and Bouchard's Nodes)

3. The Bony Injury can occasionaly produce mild joint inflammation, but is NOT A SYSTEMIC INFLAMMATORY CONDITION

4. Distribution of involvement can be mono-articular (such as following knee injury), as well as oligo-articular and poly-articular

5. DJD typically involves weight bearing or chronically used joints (eg hands of manual laborers)

RHEUMATOID ARTHRITIS

1. What is it caused by?

2. What is seen in active, untreated disease?

3. More common in Men or Women?

4. What are many patients "positive" for?

5. Can there be extra-articular disease?

1. Classic Systemic inflammatory condition.  AUTOIMMUNE rxn causing chronic synovial inflammation and joint destruction

2. Constitutional complaints are the rule in active, untreated disease

3. More commen in WOMEN than MEN

4. Many pts have a positive RF in Serum (26-90% depedning on activity and severity of disease)

5. Extra Articular findings ...

a. Rhematoid Nodules (20-30%)

b. Lung, Heart, Eye, Vascular involvement less common.

GOUTY ARTHRITIS

1. What is it caused by?

2. Men or women mostly?

3. What pattern of joint invovlement does it typically start with?

4. What is the pain like? (is anything associated with it?)

5. Does it recur?

1. Precipitation of sodium urate crystals in synovial fluid, with subsequent phagocytic ingestion and severe, acute joint inflammation

2. Occurs mostly in MEN and POST-MENOPAUSAL WOMEN

3. Usually begins as mono-articular involvement of the GREAT TOE (90%)

4. Pain is INTENSE, and FEVER is often present during acute attacks

5. Intiial episode will resolve spontaneously and recurr in about 60%.  With each recurrence, more joints may become involved in an asymmetric distribution

SEPTIC JOINT

1. What is initiated by? (most commonly?)

2. What types of joints are prone to bacterial adherence?

3. How does it usually present?

4. What can happen if not properly managed with drainage and antibiotics?

1. Bacteremia of any cause (Staph Aureus is most common) seeding joint space

2. Abnormal Joints, eps prosthetic joints

3. Usually presents as mono-arthritis with systemic inflammatory features (HOT joint), may mimic gout

4. Can destroy joint if not properly managed

SPONDYLOARTHROPATHY

1. It is a group of disorders, which may produce WHAT THREE THINGS?

2. Name five associated diseases

3. Strong association with?

4. Name SEVEN SYMPTOMS see in SPONDYLOARTHROPATHIES

1. May produce...

 a. inflammatory oligoasymmetric peripheral arthritis

 b. inflammation of the axial skeleton (sacroiliac joint and spine)

 c. Enthesopathy

2. Associated diseases include...

 a. IBD (Crohns, UC)

 b. Psoriasis

 c. Reactive Arthritis

 d. Ankylosing Spondylitis

 e. Behcet's

3. Strong association with HLA-B27

4. SYMPTOMS...

REACTIVE ARTHRITIS (formerly Reiters)

1. What is it associated with?

2. How does it manifest?

3. What is it triggered by?

4. What does the joint fluid look like?

5. May have extra-articular findings, but they are SPECIFIC, NOT SENSITIVE...Name four...

1. Inflammatory condition a/w HLA B-27

2. Manifesting as spondyloarthropathy

3. RA often triggered by urethritis/STDs/infecteous enteritis (Salmonellosis)

4. Joint Fluid is STERILE (in contrast to joint sepsis)

5. Extra-articular findings...

a. Conjunctivitis and/or Anterior Uveitis

b. Oral Ulcers

c. Hyperkeratotic lesions of palms and soles (keratoderma blennorrhagica)

d. Genital Lesions (circinate Balanitis)

SLE

Four out of the following 10 criteria are required for Diagnosis

1. Malar Rash

2. Discoid Rash

3. Oral Ulceration

4. Photosensitivity

5. Arthritis

6. Renal Involvement

7. Serositis (Pleurisy)

8. Neurologic Disease (Cerebritis)

9. Hematologic Disease (autoimmune thrombocytopenia)

10. Presence of Auto-Ab's in serum

SCLERODERMA and CREST

1. Why is it named as such?

2. What is the diffuse form called?

3. How is the diffuse form different?

4. What is the limited form called?

5. What five things are involved in the constellation of the limited form?

1. Autoimmune disease named so due to the SKIN MANIFESTATIONS of thickening, discoloration, and sclerosis.

2. The diffuse form is PROGRESSIVE SYSTEMIC SCLEROSIS

3. PROGRESSIVE SYSTEMIC SCLEROSIS more involves...

a. more pronounced Skin Involvement

b. Often involves Esophagus, Lung, Kidney

c. A common cause of morbidity and mortality is hypertensive crisis due to kidney disease

4. The limited form is called CREST SYNDROME

5. CREST SYNDROME INVOLVES...

a. Finger Calcinosis

b. Raynaud's Phenomenon

c. Esophogeal Dysmotility

d. Sclerodactyly

e. Telangiectasia

PSORIATIC ARTHRITIS

1. What is it grouped with?

2. Occurs in what % of pts with Psoriasis?

3. What is seen with the most common form of Psoriatic Arthritis?

1. Grouped with Spondyloarthropathies

2. Occurs in 7% of pts with Psoriasis

3. It is asymmetric in distribution with characteristic involvement of the DIP joints

ANKYLOSING SPONDYLITIS

1. What is it?

2. What is it associated with?

3. What age/sex is most commonly affected?

4. Similar to other spondyloarthropathies, what can also be involved?

5. In a minority, what can occur?

6. What may the disease PROGRESS to?

1. Inflam condition with predominant axial skeletal involvement

2. A/w HLA-B27 positivity

3. Young Men most commonly afflicted

4. Similar to other spondyloarthropathies, peripheral arthritis can occur

5. In a minority, eye, lung, and heart manifestations can occur

6. May progress to fusion (ankylosis) of the spine producing the classic "Bamboo Spine" appearance on X-rays

VASCULITIS

1. Are joint manifestations common with it?

2. What may be two common findings?

3. What is not seen?

4. Name 4 Vasculitic conditions we should be aware of

1. Joint manifestations are not the most striking element

2. Common findings may be arthralgia and non-specific evidence of joint inflammation

3. But, True deforming Arthritis such as occurs in RA is NOT SEEN

4. Periarteritis Nodosa, Wegeners, Temporal (Giant Cell) Arteritis, Infecteious Vasculitis

PERIARTERITIS NODOSA

1. What is it?

2. Name 3 organ systems in which involvment is common

3. But, Almost any organ except the ?? can be involved

4. Many of these pts may have serological eveidence of ??

1. It is a necrotizing vasculitis of small and medium sized muscular arteries

2. (PAN RAN) Prominent Renal, Abdominal Viscera, and Neurological involvement is typical

3. But, Almost any organ system except the LUNGS can be involved

4. Many of these pts may have serological eveidence of HEPATITIS B INFECTION

WEGENER'S GRANULOMATOSIS

1. What is it?

2. What organs does it effect?

3. Name three common presentations

1. A necrotizing granulomatous vasculitis that affects SMALL ARTERIES

2. Typically affects the small arteries of the ELK organs (ENT, Lungs, and Kidney), although ALMOST ANY ORGANS may be involved

3. Common presentations include...

a. Chronic Sinus Disease

b. Hemoptysis

c. Glomerulonephritis

TEMPORAL (GIANT CELL) ARTERITIS

1. What age group

2. Involves what vessels? (GENERAL location)

3. Three things pts commonly present with

4. What symptom should esp be taken seriously

1. Elderly

2. LARGE BRANCHES OF THORACIC AORTA

3. Pts present with refractory headache, vision change, and jaw claudication

3. Visual symptoms can---blindness

INFECTEOUS VASCULITIS

1. What is it caused by?

2. What is a good ex of this?

1. Disseminated infection may cause small vessel vasculitis, in part due to Ag-Ab complexes

2. A good ex is Subacute Bacterial Endocarditis

MALLET

MALLET: happens with basketball and get hit on tip of finger and rupture extensor tendon that inserts right on that proximal part of phalynx, because extensor tendon that normally comes out over the top is detached or strectched or ripped partially from extending that DIP.  Not an arthritic problem, it is a traumatic problem, sometimes with knife, etc.

What gout toe may look like...

Redness
Tumor
Loss of Function

The most painful arthritis you can have.  This guy's ankle is involved, may be more than one joint with gout sometimes.

*In general, bone pain is pretty uncommon

1) Metastases

2) Primary Tumor

3) HPO (hypertrophic Pulmonary Osteoarthropathy.  Causes clubbing, but also inflammation of the long bones)

4) Paget's

5) Stress Fracture (Stress fx common in women who have taken steroids, may see pain in midfoot:metatarsal bone)

6) Trauma

1) RA

2) SLE

3) OA
4) GOUT/PG

5) INFECTION

6) SPONDYLARTHROPATHIES

7) FBM

8) SARCOID

9) MANY OTHERS

1) PMR (PMR=Polymyalgia Rheumatica.  Seen in 70-80 y/os with truncal and proximal muscle pain.  Stiffness in morning, inability to move.)

2) MYOSITIS

3) THYROID DISEASE

4) ELECTROLYTE ABNORMALITIES (A lot of people on diuretics get K+ Deficient, can lead to myonecrosis and myosits, and occasionaly enough myoglobinuria to shut down kidneys (rhabdomyolysis))
5) FBM (FBM=fibromyalgia.  No lab tests, all tests normal.  Almost everywhere you touch them is painful)

1) FBM (FBM=fibromyalgia.  No lab tests, all tests normal.  Almost everywhere you touch them is painful.)

2) NEAR DEATH FROM WIDESPREAD DISEASE

IT CAN BE BOTH

YOU NEED TO NEXT ASK THEM "When you wake up in the morning, how long does it take you to get as loose as you are going to get..."AM GELLING"

1) Likely Inflam is >1.5 hours

2) Likely NON-inflam is <1.5 hours

(But as you get older, remember that everything stiffens up in the morning.)

1) REALLY bad inflammatory disease

2) Widespread tumors

3) FBM (FBM=fibromyalgia.  No lab tests, all tests normal.  Almost everywhere you touch them is painful.)

*Proximal/Truncal muscle disease suggests intrinstic muscle disorders.

1) PMR (PMR=Polymyalgia Rheumatica.  Seen in 70-80 y/os with truncal and proximal muscle pain.  Stiffness in morning, inability to move.)

2) Polymyositis/DM

3) Other Myositis (Hypothyroid can lead to myositis---proximal.)

4) Some Dystrophies

1) NEUROPATHIC DISEASE (Diabetic neuropathies.  Wrist, hand weakness, etc, suggest neuropathies, not myopathies)

2) SOME DYSTROPHIES

1) SEVERE PMR (PMR=Polymyalgia Rheumatica.  Seen in 70-80 y/os with truncal and proximal muscle pain.  Stiffness in morning, inability to move.)

2) STATINS

You have figured out that a patient's symptoms have a MUSCLE origin.  You want to figure out if WEAKNESS or PAIN is GREATER, for this will help you narrow your diagnosis. The patient says the WEAKNESS > PAIN.  What SIX things should you think of?

**Have to be careful when asking these.  "When you say weak, do you mean tired, or sleepy, or are there certain things you can't do well (take out garbage, getting out of chair etc.  If they say yes, ask them if they have these problems because of pain or not.

**Weakness> Pain in Intrinsic muscle diseases

1) Polymyositis/DM

2) Other Myositis

3) Hyperthyroidism

4) Dystrophies

5) K+ Depletion

6) Hyper-Ca2+

You have figured out that a patient's symptoms have a MUSCLE origin.  You want to figure out if WEAKNESS or PAIN is GREATER, for this will help you narrow your diagnosis. The patient says the PAIN > WEAKNESS.  What THREE things should you think of?

**Have to be careful when asking these.  "When you say weak, do you mean tired, or sleepy, or are there certain things you can't do well (take out garbage, getting out of chair etc.  If they say yes, ask them if they have these problems because of pain or not.

1) PMR (PMR=Polymyalgia Rheumatica.  Seen in 70-80 y/os with truncal and proximal muscle pain.  Stiffness in morning, inability to move.)

2) Hypothyroidism

3) FBM (FBM=fibromyalgia.  No lab tests, all tests normal.  Almost everywhere you touch them is painful)

GRADING MUSCLE STRENGTH

What are the grades?

*What is something that you need to be aware of when measuring weakness this way?

5/5=Contracts vs Full resistence

4/5 Contracts LESS well vs Full resistence

3/5 Contracts ONLY AGAINST GRAVITY

2/5=CANNOT overcome GRAVITY

1/5=Trace/Flicker of movement/Fasciculations

*PAIN CONFOUNDS MEASUREMENT OF WEAKNESS

-Have to ask pt why they couldn't hold it up, and if they say it hurt, then you think Pain.

-Giving Pain Weakness: Pt kind of faking.  You push, and they resist, then give, tehn resits, etc.  The pt basically just wants you to know how sick they are.

1) Is it bones, muscles, or joints that hurt the most?

2) Have you noticed any abnormal apperance to the painful part?

3) If you did notice an abnormal apperance to the painful part, was it a change in size, a change in color? (If see redness or swelling, you are dealing with Athritis, not with Arthralgias.)

4) How many joints are involved? (Few or Many?)

5) Have their been prior attacks? (Brief and Self Limited, or Prolonged?) (Gout is brief and self limited.  RA, SLE, lasts weeks/months)

6) Are the sx inflam or degenerative? (AM's worse than PM's) (Does gelling last >2 hours?)

PAIN-GENERAL PRINCIPLES
1) Is pain common?

2) Is it objective?

3) Can we standardize it?

4) When assesing pain, where should you first palpate?

5) How do you assess warmth?

6) What information may be very helpful when dealing with painful joints?

1) MOST COMMON and MOST PROBLOMATIC compaint of patients in all specialties

2) Totally subjective

3) No way to standardize between patients

4) Palpate first an area that should NOT be painful to JUDGE a pts PAIN THRESHOLD (mid-point of clavicles is a good starting point...then move to scapular tips...then to costochondral joints) (ANOTHER EX: If suspect Pyelonephritis, thump a few areas before CVA) (ANOTHER EX: same for testing Vertebral function with osteomyelitis)

5) Use the backside of the fingers and keep the hand moving on and off the putatitive "warm" area

6) The PATTERN of Joint involvement

1) Medical History

2) Physical

RA: SEVERE

1) If it is bad, can it involve the lower extremities as well?

2) How might this start and progress?

3) What could present similar to this?

1) YES.  RA is an inflammatory, polyarthritis of Upper and Lower Extrimity Large and Small Joints (On skeleton he showed: Upper MCP (2nd/3rd) and both knees and entire metatarsal phalyngeal row were involved)

2) May just start in one place and involved other joints.  But this would be a classic presentation

3) SLE would present the same way.

1) Does Cartilage show up on X-rays?

2) What are the cells lining the joint space?

1) RA is a disease of synovial inflammation...Soft tissue swelling and inflammation in synovium

2) If it progresses...that inflam tissue invades out across the cartilages and causes loss of the cartilages, again with even more swelling.  Behaves like an inflammatory tumor as it were.

3) Hypertophied villous inflam tissue invade and destroy cartialge...eventually producing Villous Joint, all filled with lymphocytes, Plasma cells, etcs...in some, may even appear like follicles because so chronic and severe...

Set of Knees with RA
Narrowing of Joint Spaces-Lost of Cartilage
Both sides dissovled away equally-symmetrical joint space narrowing
-Anytime bone rubs against bone, get sclerosis.  But this is NOT that sclerotic compared to the amount of joint space narrowing.  This presentation is in CONTRAST to OSTEOARTHRITIS.

CHRONIC RA

The synovium doesn't care what it invades.  It will rupture tendons, it will rupture joint capsules.   So in this chronic arthritis, you have VOLAR SUBLUXATION of digits (dominant hand is worse).  The phalynx has sunk down into the palms.  Get clasically ulnar deviation.  The tendon has slipped down medial to (in anatomical position) the metatarsal head, when try to extend, it may flex hand instead because dropped down into groove.  Non-dominant hand is less involved

These are the kinds of things you get chronically in an inflammatory destructive osteolyticarthritis like RA

If a patient presents with joint swelling and pain, why might you ask about...

1) Raynaud's

2) Sun sensitive Facial Rash

3) Oral or Nasal Ulcers

4) Recurrent miscairrages

5) Pleurisy

6) Psychosis

7) Seizures

8) Known Kidney Problems

TO RULE OUT/IN LUPUS.  THESE CAN ALL BE A PART OF SLE

IS THIS RIGHT???

SEE NOTES/MAIN SLIDE ON THESE THINGS...BETTER DESCRIBED THERE...

1) ANKYLOSING SPONDYLITIS

-Can get WITHOUT an associated illness
-SPine and sacroiliac joints especially
-worse in morning
-can keep you awake all night
-if persists, whole spine can become fused into a column

2) PSORIATIC ARTHRITIS

-It behaves like RA, but is oligoAsymmetrical, can involve spine, and unlike RA, tends to fuse and ankylose joints including the spine.

3) IBD w/ ARTHRITIS (Crohns, UC)

-Both peripheral arthritis and Spondylitis that is ankylosing

4) REACTIVE ARTHRITIS

-can occur after certain infections...SALMONELLA, Yersinia, Shigella or STDS...looks like Psoriatic disease  SEE NOTES/MAIN SLIDE ON IT
5) BEHCET'S

-seen in East.  Can cause spondylitis or peripheral arthritis.

S, C=SCLEROSIS

O=OSTEOPHYTES

R=REGIONAL

N=NARROWING

WHAT ARE SOME TRICKY JOINTS TO EXAMINE...

1) Within the Shoulder, and what is key thing to do?

2) Within the Elbow, and what is key thing to do?

3) Within the thoracic spine, and what is the key thing to do?

1) Shoulder: SCAPULOTHORACIC MOVEMENT: Be sure to FIX the SCAPULA

2) Elbow: PRONATION/SUPINATION:Patients will use their Shoulders to cheat: Be sure to Measure elbow pronation and supination with elbow flexed at 90 degrees

3) Thoracic Spine: ROTATION.  Ask patient to perform the Pelvic Twist, but they need to do so WHEN SEATED

MOTION IN SPINE (FLER) (Flex, Laterally Flex, Extend, Rotate)

1) Cervical Spine

2) Thoracic (Dorsal):

3) Lumbar

1) FLER (ALL)

2) R + Ribs rotating on thoracic spine where ribs articulate on vertberal column when expand chest as breathe inwards.  If costovertebral and costotransverse joints fused, cant do this movement.  Put your hands on back, and have them breathe in, and can see possibly see that this is correct motion.

3) FLE (does not allow rotation because Lumbar vertebral body Fascet? joint back here IS VERTICAL and doesn't allow for rotation.

PEARLS IN SPINE DISEASE

1) Where is 90% of Hip Pain localized?

2) Over age 45, what is 50% of shoulder pain due to?

3) What can mimic CAD and why?

4) Do many of these above patients have neuro exam abnormalities suggesting L-S or C-spine disease?

1) 90% of Hip Pain is localized at or behind the trochanter, and is from L-S Spine DJD (**So even though pt will say their hip hurts, it is actually from Spine**)

2) Over age 45, 50% of shoulder pain is due to DJD in the cervical spine

3) The cervical roots innervate the pectoral an other upper chest muscles as well as those in the arm, and can mimic CAD

4) FEW of the above pts have neuro exam abnormalities suggesting L-S or C-spine disease (*Just have pain referred to that area*)

SPINAL "PEARLS"

1) With the OA of aging, what spinal movement is first to go?

2) in 95% of patients over 40 who present with "hip" pain, where is it localized and what is it due to?

3) In 50% of patients over 40 who present with poorly localized shoulder pain, what is the cause?

1) With the OA of aging, Lateral Bending of the C-Spine is first to go.

2) in 95% of patients over 40 who present with "hip" pain, it is localized in the buttock and is due to L-S root disease

3) In 50% of patients over 40 who present with poorly localized shoulder pain, C-Spine radiculopathy is the cause

GAIT

1) Antalgic

2) Trendelenburg

3) Heel and Toe Walking

1) ANTALGIC GAIT
-Put tack in right shoe, hurry off that foot (ANTALGIC...against the pain)
-Very often, people will come with all kinds of painful gates (if spend more time on painful side, could be malingerer)

2) TRENDELENBURG GAIT
-When walk, pelvis tilts, spine shifts back and forth.  When on right leg, muscles on other side are pulling this side down.  Some people with severe Trendelenberg gates, that does not happen.  Instead, lean out over the hip. 

3) HEAL AND TOE WALKING
-Have them do this, esp if not sure what wrong or if they have painful gate.
-Tells you if they are faking gate (MAY DISTRACT THE MALINGERER)
-Also tells you if they have dorsiflexion (L4-L5) and plantarflexion (S1) strength (might lose these if have disk)
-Foot drop (Peroneal Nerve Injury), can't walk on heals because one foot too weak to dorsiflex

FROM VASCULITIS:
Findings in Lariche Syndrome...

Leriche syndrome, caused by severe atherosclerotic narrowing of the aorta and/or iliac arteries. The findings include...

 a. decreased-absent femoral pulses

 b. impotency

 c. thigh/buttock fatigue with walking

 d. atrophy of the buttock musculature

all due to decreased arterial perfusion.