MSK

Question 1

• Pain over AC joint, and on lifting affected arm, Type III-VI presents with obvious deformity.
• Inspection: Distal clavicle prominent and superior to acromion with Type II injuries.
• Palpations: Tenderness to AC joint.
• ROMs: Full ROM. Any motion, especially abduction, causes pain.
• Muscle test: Decreased general muscle strength due to pain.
• Neuro: Unremarkable unless an injury to the brachial plexus “stinger” is present.
• Special test: Any motion of the shoulder causes pain.

Answer 1

Acromioclavicular (AC) Injury.

Rad
* Anterior-posterior (AP) and axillary of bilateral shoulders confirm Type II- VI.
* Type I radiographs are negative. clinical presentation
* Type III injuries, some AC joint widening.
Treatment
Type I and II:
* Sling x 24-48 hours, Ice. Analgesics.
* Home exercise program that focuses on ROM and general shoulder strengthening.
* Return to full duty as pain permits, usually within 4 weeks.
Type III
* Orthopedic consultation
* Sling x 24-48 hours, Ice. Analgesics.
* Home exercise program that focuses on ROM and general shoulder strengthening.
* Light duty until eval by orth.
Type IV-VI
* Orthopedic consultation, will require surgery
* Sling x 24-48 hours, Ice. Analgesics
* Light duty until eval by orth.
* MEDEVAC

Question 2

• Pain over fracture site and with arm motion.
• Inspection: Bony deformity, bump, shoulder droop.
• Palpations: Gentle pressure over fracture will elicit pain.
• ROMs: Decreased due to pain. Grinding noted when patient attempts to move arm.
• Muscle Test: Decreased due to pain
• Neurovascular: Assess axillary, musculocutaneous, median, ulnar and radial nerve function
• distal to the fracture, assess radial pulse and cap refill.
• Special Tests: Positive Cross-Body test with possible grinding.

Answer 2

Fracture of the Clavicle.

Rad
* AP and 10-degree cephalic tilt radiographic views confirm most clavicle fractures.
Treatment
* Ice, Analgesics (consider narcotic-level pain control)
* Orthopedic consult.
* Mid-shaft fracture with minimal displacement and no neurovascular injury, Figure-of-8 strap for 6-8 week.
* All fractures require referral – MEDEVAC
Red Flags
* Painful nonunion after 4 months of treatment referral back to orth.
* Widely displaced lateral or mid-shaft fractures or segmental fractures

Question 3

Symptoms
* Gradual onset of anterior and lateral shoulder pain exacerbated by overhead activity.
* Night pain and difficulty sleeping on affected side.
* Palpations: Tenderness greater or lesser tuberosity, bicipital groove.
* ROMs: Full AROM, possibly limited due to pain, worse between 90 to 120 degrees.
* Muscle Test: Flexion and abduction limited by pain.
* Neurovascular: unremarkable
* Special Tests: Neers and Hawkins.

Answer 3

Impingement Syndrome of the Shoulder.

Rad: AP and axillary (normal), Narrowing of sub acromial space suggests long standing rotator cuff tear. MRI with gadolinium is helpful in establishing exact soft tissue pathology.
Treatment
* NSAIDS, Ices, Light duty, Home Exercise program.
* Physical therapy consults if failed local management.
* Referral orthopedic if failed conservative management after 2-3 months or other pathology is suspected.

Question 4

• Chronic shoulder pain for several months, Specific injury that triggered pain.
• Night pain and difficulty sleeping on the affected side.
• Complaints of weakness, catching and grating especially overhead activities.
• Inspection: Shoulder may appear sunken, indicating atrophy of the infraspinatus
• following a long- standing cuff tear.
• Palpations: Tenderness over greater tuberosity, Grating sensation can be felt at tip of shoulder.
• ROMs: full PROM, Cannot raise arm with large tears. Can only shrug or hike shoulder upward.
• Muscle Test: Abduction, forward flexion and external rotation may be limited.
• Neuro: Usually intact
• Special Tests: Positive Drop Arm test, Empty Can tests.

Answer 4

Rotator Cuff Tear

• Rad: Radiographs needed to evaluate subacromial space, MRI necessary to confirm diagnosis.
  Treatment
• NSAIDS, Ices, Light duty, Home Exercise program.
• Physical therapy consults if failed local management.
• Referral orthopedic if failed conservative management after 3-6 months. (Long standing)
  Red Flag (ACUTE)
• Failure of 6 weeks of nonsurgical treatment is an indication for further evaluation.
• Acute traumatic tears should be surgically repaired immediately or no later than 6 weeks post injury.
• Patients younger than 55 years old should be considered for surgical repair as tears could enlarge with time.

Question 5

common in people who pull, lift, reach, or throw for work/recreation.
* Anterior shoulder pain that radiates distally down the arm over bicep muscle(proximal), aggravated by lifting, pulling, overhead activity.
* Inspection: Shoulder will appear normal on inspection typically
* Palpations: Tender to palpation in the bicipital groove of the humerus
* Neuro: Neurovascular intact
* Special Tests: Speeds, Yorgason

Answer 5

Biceps Tendon Injury

Treatment
Mainstay of treatment:
* NSAIDS, Ices, Light duty, Home Exercise program.
* Physical therapy consults if failed local management.
* If rupture is suspected, then ortho consult,

Question 6

• Anterior instability: sensation of the shoulder slipping out of joint when arm is abducted and externally rotated.
• Inspection: Joint disfigurement (currently dislocated)
  o Anterior dislocation- most common, Patient supports arm in neutral position.
  o Posterior dislocation- patient holds arm in adduction and internal rotation.
• Palpations: General tenderness noted throughout shoulder
• Special Tests:
  o Sulcus test-inferior laxity,
  o Apprehension test- anterior instability,
  o Anterior/Posterior Drawer test - anterior/posterior laxity
  o Jerk test- posterior instability

Answer 6

Shoulder Instability

Rad: AP and axillary views, MRI for soft tissue structures.
Treatment
* Reduce acute dislocations: Valium, Re-evaluate axillary nerve function after reduction
o Stimson technique- gravity assisted with patient lying on stomach.
o Longitudinal traction- elbow at 90 degrees flexion while longitudinal traction is applied to the humerus. Gently rotate arm.
* Immobilize arm in a sling in neutral rotation.
* Light duty to include no active use of arm for 2-3 weeks.
* Begin rotator cuff strengthening 2-3 weeks post reduction. Physical therapy consults.
* Referral Decisions: First time dislocations or evidence of neurovascular compromise require orthopedic evaluation for possible surgery – MEDEVAC. Call first.

Question 7

Causes
* Tries to prevent falling by grabbing hold of an object.
* Suddenly tries to lift a heavy object, Forceful throwing, excessive overhead activity.
Symptoms
* Anterior shoulder pain (in overuse injury)
* Clicking/clunking of the shoulder in certain positions
* Swelling, parasthesias, severe night pain uncommon
* Recommend Obriens and Speeds
* Palpate the shoulder: Special attention to biceps tendon, Inspect ROM and scapular motion.

Answer 7

Labrum Tear and SLAP Lesion.

Call?

Question 8

3 main phases of pain and injury. Post injury.
* Diffuse, severe, and disabling shoulder pain: Increasing stiffness. 2-9 months.
* Stiffness and severe loss of shoulder motion with pain less pronounced. 4 to 12 months.
* Recovery phase: stiffness and gradual return of shoulder motion. 5-24 months.
Concern for adhesive capsulitis is raised:
* Severe pain that is worse at night “Nagging pain.”
* Dressing ROM in the shoulder
* Issues with work or activities of daily living, Varying degrees of impaired function.
* Often with history of shoulder injury and immobilization.
Symptoms:
* Inspection: normal, Possible atrophy secondary to limited use of shoulder
* Palpations: Varying degrees of tenderness
* ROMs: ROM reduction is likely most significant finding, Significant reduction in both passive and active ROM in two or more planes.
* Muscle Test: Strength 4-5/5
* Neuro: Neurovascular intact
* Special Tests: No specific manipulative maneuvers
* Rad: Plain film: normal, MRI for more challenging cases.

Answer 8

Adhesive Capsulitis.

Treatment
* Early mobilization for those with shoulder injuries, Avoid slings when possible.
* Shoulder motion exercises, Physical therapy consult.
* NSAIDs, Tylenol
* Referral Decisions: patients not responding to conservative management, Sports medicine for injections of steroid, Ortho for surgery.

Question 10

• Gradual onset of pain in lateral elbow and forearm during activities involving gripping and wrist extension, Lifting, turning screwdriver, Hitting backhand in tennis, Excessive typing.
• Inspection: Typically unremarkable
• Palpations: Tenderness over common extensor origin, 1cm distal and slightly anterior to lateral epicondyle.
• ROMs: Full AROM
• Muscle Test: Wrist extension and grip strength limited by pain
• Neuro: unremarkable
• Special Tests: Pain in lateral epicondyle with resisted extension of the wrist

Answer 10

Lateral tendinosis: Tennis Elbow,

Rad: Plain radiographs rarely needed, Diagnosed clinically
Treatment
* Light duty/duty modifications, NSAIDS
* Tennis elbow strap for comfort
* Pain free stretching and forearm strengthening
* Consult to physical therapy if conservative management fails
* Failure of conservative management indicates referral to orth, Steroid injection.

Question 11

• Gradual onset of pain at medial aspect of elbow. Exacerbated by activities that involve wrist flexion and forearm pronation. Golf swing, Baseball pitching, Pull-through stroke of swimming, Weight-lifting, Bowling.
• Inspection: Typically unremarkable
• Palpations: Tenderness just distal to medial epicondyle
• ROMs: Full AROM
• Muscle Test: Wrist flexion and pronation limited by pain
• Neuro: unremarkable
• Special Tests: Pain in medial epicondyle with resisted flexion of the wrist

Answer 11

Medial tendinosis: Golfer’s elbow, bowler’s elbow,

Treatment
* Light duty/duty modifications, NSAIDS
* Tennis elbow strap for comfort
* Pain free stretching and forearm strengthening
* Consult to physical therapy if conservative management fails
* Failure of conservative management indicates referral to orth, Steroid injection.

Question 12

• Sudden (infection or trauma) or gradual (chronic) swelling in the affected area.
• Inspection: May be large mass over elbow
• Palpations: Tenderness over the elbow
• ROMs: Elbow flexion and extension may be limited by pain.
• Muscle Test: 4-5/5
• Neuro: unremarkable
• Special Tests: None

Answer 12

Olecranon Bursitis

Rad: Aspiration maybe be diagnostic and therapeutic. WBC count, crystals, gram stain and culture. Radiographs needed to rule out fracture of olecranon process (trauma).
Treatment
* Light duty focused on activity modification avoiding hyperflexion against hard surfaces.
* Mild cases: NSAIDs, Pressure wrap, Ice.
* Moderate to severe cases should undergo aspiration of fluid (refer for orthopedic)
* Septic olecranon bursitis requires organism specific antibiotics. Sign of infection. (refer for treatment). MEDVACE