Musculoskeletal Assessment and Diagnosis PDF

1. Discuss the assessment and diagnosis of Temporomandibular Joint disorders. ○ Inspect the face and TMJ for swelling, redness and symmetry. Swelling may manifest as a rounded bulge anterior to the external auditory meatus. Facial asymmetry is often a physical present...

1. Discuss the assessment and diagnosis of Temporomandibular Joint disorders. ○ Inspect the face and TMJ for swelling, redness and symmetry. Swelling may manifest as a rounded bulge anterior to the external auditory meatus. Facial asymmetry is often a physical presentation in TMJ disorders. ○ Assess the patient for unilateral chronic pain with chewing, jaw clenching, or teeth grinding often accompanied by headache. ○ Palpate muscles of mastication. To locate and palpate the joint, place the tips of your index fingers just in front of the tragus of each ear and have the patient open his or her mouth. Your fingertips should drop into the joint spaces as the patient’s mouth opens. You may hear and or feel snapping or clicking which is normal in some people and does not necessarily mean an issue is present. ○ Assess range of motion of the jaw by having the patient perform opening and closing; protrusion and retraction; side-to-side motions. 2. Discuss the assessment and diagnosis of common foot problems ○ Inspect the ankle and foot for deformities, nodules, swelling, calluses, corns. Palpate- the ankle joint for swelling and tenderness, the Achilles tendon for nodules, tenderness. Assess the ankle and foot ROM, plantar flexion and extension, inversion and eversion. ○ Achilles tendonitis = Focal thickening and tenderness in the Achilles tendon are commonly found in Achilles tendinitis.Tenderness and thickening of the tendon, at times with a protuberant posterolateral bony process of the calcaneus, suggests Achilles tendinitis. ○ Achilles rupture = A defect in the muscles, tenderness, and swelling may signal a ruptured Achilles tendon. ○ Plantar Fascitis- the presence of focal heel tenderness at the attachment site of the plantar fascia is a sign of plantar fasciitis, also pain standing after rest. ○ Plantar Wart- is a hyperkeratotic lesion caused by human papillomavirus, located on the sole of the foot. It can be mistaken for a callus. Characteristic are small dark spots that make the wart appear stippled. The difference is with a plantar wart it is tender if pinched side to side, while a callus is tender to direct pressure ○ Gout- most often great toe but can affect any joint. Note for signs of redness, hot, tender, and swelling. ○ Hallux Valgus = exhibits as lateral deviation of the great toe and enlargement of the head of the first metatarsal on its medial side which results in the formation of a bursa or bunion. This bursa may become inflamed. This can affect women 10 times more likely than men.(high heels) ○ Morton’s neuroma = to determine Morton's neuroma look for any tenderness over the plantar surface between the third and fourth metatarsal heads, from perineural fibrosis of the common digital nerve  due to repetitive nerve irritation. Check for any pain radiating to the toes when you press on the plantar interspace and squeeze the metatarsals with your other hand. Symptoms common to morton’s neuroma include numbness, aching, hyperesthesia, and burning from the metatarsal heads into the third and fourth toes. 3. Discuss the assessment and diagnosis of Carpal Tunnel Syndrome ○ Clinical features specific to carpal tunnel are pain or numbness of the first three fingers of the hand, but not in the palm, especially present at night. Patients may also have loss of sensation in distribution of the medial nerve: palmar surface of thumb, index, middle, and medial 4th fingers. Patients may also notice a developed history of dropping everyday objects more often than usual. ○ Assess = The most sensitive test is the presence of weak abduction of the thumb. There are also two additional signs that can help identify the presence of carpal tunnel: Tinel’s sign: tingling with tapping over the median nerve as it enters the carpal tunnel Phalen’s sign: numbness or tingling with pressing backs of hands together in acute flexion for 60 seconds 4. Discuss the assessment and diagnosis of common joint problems such as arthritis ○ Arthritis is a disease that causes joint inflammation, pain, stiffness, swelling, and limited movement. It can affect any joint in the body. Begin with inspection and palpation of all joints for pain and tenderness, and signs of swelling. ○ Rheumatoid Arthritis in the Hands is an autoimmune disease which affects the synovial membrane and joint deformity. Symptoms are usually symmetrical. If progression to chronic rheumatoid arthritis signs and symptoms present include ulnar deviation, swollen and thickened knuckles, muscular atrophy, rheumatoid nodules, swan neck deformities, and boutonniere deformities. ○ Osteoarthritis is characterized by degenerative changes in articular cartilage. It specifically affects weight bearing joints, the progression leads to bone on bone contact. Osteoarthritis can be unilateral or bilateral. Heberden's nodes- DIP joints common (The distal interphalangeal joint ) Bouchard's nodes – PIP less common (proximal interphalangeal joints) 5. Discuss assessment techniques/tests to diagnose acute shoulder disorders ○ Just as you would for every part of the exam begin with inspection and palpation to guide the rest of the exam. During this portion you can uncover signs and symptoms of more specific issues like the few that follow: ○ Bursitis/Bursal Tear = Bursal tears there may be swelling on inspection, with bursitis there is tenderness on palpation of the bursa.  Knowing where bursa are located anatomically important in identifying bursitis- pain with firm palpation anterior or posterior joint ○ Rotator cuff sprains, tears, & tendon rupture- are the most common cause of shoulder pain. ○ Drop Arm sign (controlled abduction to shoulder level followed by controlled adduction)- requires lateral raise or abduction to shoulder, positive sign indicated a rotator cuff tear ○ Neers impingement = A positive test is indicated by pain in the anterior or lateral shoulder when in flexion. To perform press on the patient's scapula to prevent scapular motion with one hand and raise the patient’s arm with the other. This compresses the greater tuberosity of the humerus against the acromion. ○ Hawkin’s impingement = To asses for Hawkin’s flex the patient’s shoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament. ○ Supraspinatus is weakness on abduction ○ Infraspinatus is weakness during external rotation ○ Biceps tendonitis is performed to test infraspinatus strength Pain with resistance in the biceps on flexion of elbow to 90 degrees with thumbs up/place your hands on the forearm just above the wrist and ask the patient to push against your hand while continuing to try to flex against resistance pain or inability to flex positive sign for biceps tendonitis ○ AC joint arthritis is present with pain with adduction (cross over test) indicative of arthritis ○ Adhesive capsulitis also known as frozen shoulder = Unable to internally and externally rotate Additional discussion questions Ankle Sprain, heel spur, gout and plantar fasciitis Tinel’s test, McMurray test, anterior draw test, drop arm test and Phalen’s test Pterygoid weakness, mandible fracture, temporomandibular fracture and osteomyelitis Ganglion, Heberden’s node, chronic tophaceous gout, rheumatoid arthritis, osteoarthritis, olecranon bursitis, epicondylitis, epicondylar fracture and ankylosing spondylitis, Extra notes from textbook: In inflammatory joint disorders (e.g., RA), rest tends to worsen the pain, whereas activity improves it. In mechanical joint disorders (e.g., OA), activity tends to increase the pain and stiffness, and rest improves the symptoms. Extra Articular pain occurs in inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis) as well as in sprains from stretching or tearing of ligaments.  Note that the symptoms of decreased joint movement and stiffness can help you decide if the pain might be articular (pain coming from the joint). Sciatica is radicular gluteal and posterior leg pain usually caused by impingement nerve roots at the L4–S1 root levels Inflammation signs ○ Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3) soft tissue structures, such as bursae, tendons, and tendon sheaths. ○ Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint or with nearby tissues if both joints are involved. ○ Redness. Redness of the overlying skin is the least common sign of inflammation near the joints and is usually seen in more superficial joints like fingers, toes, and knees. ○ Pain or tenderness. Try to identify the specific anatomic structure that is tender. Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often accompanied by effusion. Palpable joint fluid is present in effusion. Tenderness over the tendon sheath is seen in tendinitis. Rotator cuff disorders are the most common cause of shoulder pain in primary care. Tenderness distal to the epicondyle (elbow bone) is common in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (pitcher’s or golfer’s elbow). Nerve hand supply Heberden nodes (hard dorsolateral nodules on the DIP joints) and Bouchard nodes (hard dorsolateral nodules on the PIP joints) are common findings in OA. The MCPs (The metacarpophalangeal (MCP) joint, also known as “the knuckle,”) are often boggy or tender in RA but are rarely involved in OA. Pain with compression also occurs in posttraumatic arthritis. Focal tenderness after trauma may suggest underlying fracture  ○ Tinel sign by repeatedly tapping over the course of the median nerve in the carpal tunnel, as shown ○ Phalen sign, ask the patient to hold the wrists in full flexion and juxtaposing the dorsum of each hand against each other for 60 seconds with the elbows fully extended, numbness and tingling = positive sign ○ Lateral deviation and rotation of the head are seen in torticollis, often from contraction of the sternocleidomastoid muscle. Tenderness over the sacroiliac joint is common in sacroiliitis and ankylosing spondylitis. ○ Ankylosing spondylitis, an inflammatory polyarthritis, most common in men younger than 40 yrs. Most hip problems appear during the weight-bearing stance phase. Leg shortening, and external rotation are common in hip fracture. McMurray Test. With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in  external rotation. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a tear. ○. Anterior Drawer Sign. With the patient supine, hips flexed, and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Sit on the patient’s foot to ensure it does not move during the maneuver. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Lack of a firm endpoint with excessive movement may indicate the ACL is no longer intact. ○ Lachman Test. Place the knee in 15° of flexion and mild external rotation. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. With the thumb of the tibial hand on the joint line, forcefully and simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion. There should be a firm endpoint to any forward movement. Lack of a firm endpoint with excessive movement may indicate the ACL is no longer intact. ○ Rotator Cuff Tendinitis (Impingement Syndrome) ○ Repeated shoulder motion, for example, from throwing or swimming, can cause edema and hemorrhage followed by inflammation, most commonly involving the supraspinatus tendon. Patients report sharp catches of pain, grating, and weakness when lifting the arm overhead.  ○ Rotator cuff tear = Injury from a fall, trauma, or repeated impingement against the acromion and the coracoacromial ligament may cause a partial- or full-thickness tear of tendons in the rotator cuff, especially in older patients. Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead. ○ Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. In a complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder when trying to raise the arm and a positive “drop arm” test when trying to lower the arm ○ Ganglion = cystic, round, usually nontender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist. The cyst contains synovial fluid arising from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic cavity. Flexion of the wrist makes ganglia more prominent if present on the dorsum of the wrist with extension tending to obscure them. Ganglia may also develop on the hands, ankles and feet. They can disappear spontaneously. ○  Pterygoid muscles, internally between the tonsillar pillars at the mandible (difficult to palpate) is a muscle of mastication assess function/ weakness in TMJ Heel spur = also known as a calcaneal spur, is a bony growth that forms on the heel bone ○