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Classify joints based on the degree of movement between bones

Synostoses (no movement) Skull bones
Syndesmoses (dense CT only) Interosseous ligament of ITJ
Posterior region of sacroiliac joints
Symphyses (pad of fibrocartilage) Pubic symphyses, midline of body.
Diarthroses (has capsule with synovial
Elbow and knee

2. Recall histologic features and physiology of the synovial membrane

Synovial fluid is derived from blood plasma but with a high concentration of hyaluronan
There are two types of synoviocytes that are specialized
1. Macrophage-like (Type A) (25% of cells)
- Derived from monocytes
- Remove tissue debris from synovial fluid
- Resemble epithelium, has no basal lamina, no cell junctions
- Important in regulating inflammation
2. Fibroblast-like (Type B)
- Derived from mesenchyme
- Synthesizes hyaluronan
3. Define terms associated with musculoskeletal complaints

4. Evaluation of a patient with MS complaints

A. Goal: accurate diagnosis, timely therapy, no excessive testing, unnecessary testing,
identification of red flag conditions
Red flag conditions (must be diagnosed stat! SAGO F): Septic Arthritis, GOut, Fracture
B. Approach to history taking
1. Is it articular? Non-articular?
2. Is it inflammatory? Non-inflammatory?
3. Is it acute or chronic in duration?
4. Is it localized (monarticular) or widespread (polyarticular)
Articular Structures Nonarticular (Periarticular Structures)
Synovium (ial fluid) Tendons
Articular cartilage Bursae
Intraarticular ligaments Muscle
Joint capsule Fascia
Juxtaarticular bone Bone
Deep, diffuse pain; swelling, crepitation, Seldom do the articular structure
instability, locking, deformity characteristics

Inflammatory Disorders Noninflammatory Disorders

Identified by the four cardinal signs of Related to trauma, repetitive use (bursitis,
inflammation, system symptoms, or lab tendinitis), degeneration/ineffective repair
evidence (CRP, ESR, thrombocytosis, (OA), neoplasm (pigmented villonodular
anemia, hypoalbuminemia) synovitis) or pain amplification

Pain without synovial swelling or warmth,

daytime gel phenomena, normal lab
Morning sitfness related to inflammatory Precipitated by brief periods of rest and
disorders is precipitated by prolonged rest. exacerbated by activity
Improves only with activity or anti-
inflammatory medications.
5. Concepts on focused physical exam on the joints

Excess mobility of joint ligaments ligamentous laxity

The signs of inflammation are
1. Swelling boggy, doughy, synovial fluid effusion, bursae, tendons, tendon sheaths
2. Warmth use backs of fingers to compare involved joint with contralateral joint
3. Tenderness trauma can also cause this finding aside from inflammation
4. Redness least common sign of inflammation near the joints and is usually seen in
superficial joints.

Movement Muscles that Affect Movement Patient Instructions

Flexion Anterior deltoid, pectoralis Raise your arms in front of
major, coracobrachialis, biceps you and overhead.

Extension Triceps brachii Raise your arms behind
Posterior deltoid you
Latissumus dorsi
Teres major

Try to breach post/delete later

Abduction Supraspinatus Raise your arms to the
Middle Deltoid side and overhead
Serratus Anterior
Humeral motion: arm to
shoulder level at 90

Scapulothoracic motion:
Patient turns palms up and
raise the arms an
additional 60 degrees
Adduction Pectoralis major Cross your arm in front of
Corachobrachialis your body
Latissimus dorsi
Teres major
Internal Rotation Subscapularis, anterior deltoid, Place one hand behind
Pectoralis major, teres major, your back and touch the
latissimus dorsi shoulder blade
External rotation Infraspinatus, Teres minor, Panatang Makabayan
posterior deltoid pose
Acromioclavicular joint Palpate and compare both joints. Adduct the patients arm
across the chest. This is called the crossover test.
Overall shoulder rotation Touch the opposite scapula. Touching from above tests
abduction and external rotation. Touching from below
tests adduction and internal rotation. (Apley scratch test)

Pathology: Rotator cuff disorder, adhesive capsulitis

Rotator cuff Press on the scapula to prevent scapular motion with one
hand and raise the patients arm with the other. This
compresses the greater tuberosity of the humerus against
the acromion. (Neers impingement test)

Flex the patients shoulder and elbow to the 90 degrees 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
coracoacromial ligament (Hawkins impingement test)

Pathology: Pain indicates arthritis or rotator cuff tear

Forearm supination Flex the patients forearm to 90 degrees at the elbow and
pronate the patients wrist. Provide resistance when the
patient supinates the forearm

Pathology: biceps long head inflammation and rotator cuff

Flexion Biceps brachii, brachialis, Bend your elbow
Extension Triceps brachii, anconeus Straighten your elbow
Supination Biceps brachii, supinator Turn your palms up
Pronation Pronator tres, pronator Turn your palms down
Wrists and Hands
When fingers are relaxed they should be slightly flexed
Abnormal finger alignment flexor tendon damage
Diffuse swelling arthritis or infection
OA: Heberdens nodes (specific for OA) at DIP, Bouchards nodes at PIP joints