Far Eastern University – Nicanor Reyes Medical Foundation passive range of motion due either to stiffness or to

CD B PD LEC: MUSCULOSKELETAL SYSTEM pain.

Dr. Galdones, MD
EXTRA-ARTICULAR STRUCTURES
MUSCULO-SKELETAL SYSTEM - Periarticular ligaments: rope-like bundles of collagen
fibrils that connect bone to bone
TYPES OF JOINTS - Tendons: collagen fibers connecting muscle to bone
TYPE FEATURE KINDS EXAMPLES - Bursae: pouches of synovial fluid that cushion movement
Synovial Freely movable Spheroidal Shoulder, Hips (Ball of tendons and muscles over bone or other joint
& Socket) structures
*May swell, (+) - Muscle
Hinge Elbow & Knee (only - Fascia: soft tissue that covers the muscle
synovial
flexion and - Bone
membrane; m/c
extension) - Nerve
joint involved in
Condylar Temporo - Overlying Skin
patient
-mandibular joint
complaint
(TMJ) *From Bates:
Cartilagenous Slightly Vertebral bodies; - Extra-articular disease typically involves selected
movable symphysis pubis regions of the joint and types of movement
- Extraarticular: painful only during active but NOT in
Fibrous Immovable Sutures of the
passive movements
skull
- Passive movement: with assistance in ROM
- Active movement: without assistance in ROM
STRUCTURE OF THE JOINT
THE HEALTH HISTORY
- General Data
- Chief Complaint
- History of Present Illness
- Past Medical History
- Family History
- Personal and Social History
- Review of Systems

SEQUENCE OF ELICITING MSK HX

- example of a synovial joint; all parts of the joint are
- Demographic Profile
potential sources of pain, especially during inflammation
- Problem Identification/Presenting symptom/CC
- Problem Evaluation
ARTICULAR STRUCTURES
- Nature of MSK involvement
- Joint Capsule
- Extra-articular manifestations
- Articular Cartilage: collagen matrix composed of ions and
- Functional history
water, allowing cartilage to change in shape in response to
- Drug history
pressure or load, being a cushion for any underlying bone.
- Review of relevant information
In plain radiography, appears as a space.
- Synovium
DEMOGRAPHIC PROFILE
- Synovial Fluid: provides nutrition to the adjacent relatively
- AGE
avascular articular cartilage
o Infants: Kawasaki disease; rheumatic condition
- Intra-articular ligament
o Children: Henoch schonlein purpura; Rheumatic
- Juxta-articular bone
condition; pts c/o joint pain, rashes, abdominal pain
o Reproductive age: SLE, rheumatoid condition
*From Bates:
- SEX
- Articular disease typically involves swelling and
o Female: SLE, RA
tenderness of the entire joint and limits both active and
o Male: Ankylosing spondylitis (AS) for young; gout for
50 yrs old above

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LECTURE: MUSCULO-SKELETAL SYSTEM AD ASTRA PER ASPERA
 o *gout is not common in women who are not yet at - Fatigue
menopausal age - Emotional lability
- OCCUPATION
o Typist: CTS (Carpal Tunnel Syndrome); Median Nn NATURE OF MUSCULO-SKELETAL INVOLVEMENT
o Office clerk: LBP (Low Back Pain); can have various - Number of Joints Involved: can be used for differential
causes diagnosis
- HAND DOMINANCE o Monoarticular: 1 joint
o De Quervain’s Tenosynovitis: AbPL & ExPB tendons  ex: early gout, trauma, septic arthritis
o Golfers/Tennis Elbow (Epicondylitis) o Oligoarticular: 4 or less
 ex: Psoriatic arthritis, reactive arthritis
PROBLEM IDENTIFICATION: chief complaints o Polyarticular: 5 or more ex: Rheumatoid Arthritis
PROBLEM EVALUATION: Example: Pain - Distribution of Joint Involvement
- Where is the Pain? Bone? Joints? Soft Tissues? o Peripheral vs Axial
- What is the Pain? Characteristic? Quality? Description?  Peripheral: Knee, MCPs, Elbow Axial: Spine, SIJ
- Why is there Pain? Aggravating and Relieving factors? o Small (hand joints) vs Large (hip, knee, ankle)
o Upper vs Lower Extremities
*SEVEN ATTRIBUTES OF A SYMPTOM (PQRST)  ex: Gout: presents primarily in the 1st MTP
- Location. Where is it? Does it radiate? (Podagra)
- Quality. What is it like? o Symmetrical vs Asymmetrical
- Quantity or severity. How bad is it? (For pain, ask for a  ex: RA: m/c in the female, reproductive age
rating on a scale of 1 to 10) group, c/o arthritis in the small joints and has
- Timing. When did (does) it start? How long does it last? symmetrical pain
How often does it come? *Reactive arthritis more common asymmetrical
- Setting in which it occurs. Include environmental factors, manifestation
personal activities, emotional reactions, or other - Temporal Profile: pattern of manifestation
circumstances that may have contributed to the illness. EPISODIC ARTHRITIS - Intermittent pattern (ex:
- Remitting or exacerbating factors. Is there anything that - Gout)
makes it better or worse? RELAPSING & REMITTING - On and off pattern (ex: RA)
- Associated manifestations. Have you noticed anything else
ADDITIVE ARTHRITIS - Location of pain is
that accompanies it?
increased
- (ex: Reactive Arthritis)
Example: 22 year-old female presenting with bilateral hand
MIGRATORY ARTHRITIS - Pain transferred to another
pains
area; do not confuse with
- Intra- or extra-articular? radiating (ex: Acute
- Acute or chronic?
- Rheumatic Fever)
- Is there inflammation?
PERSISTENT & OFTEN - Constant pain that can
- How many joints involved?
INSIDIOUSLY PROGRESSIVE progress (ex: OA, Spinal
- Which joints are involved?
- Stenosis)
- Functional loss/disability
- Family history
- Inflammatory vs Noninflammatory
o Features of Inflammation: Joint stiffness, Acute
CATEGORIES OF PAIN
swelling, Heat, Erythema
- ACUTE: Trauma, fractures, tendon ruptures, osteomyelitis,
o Severity of Symptoms
acute gout, septic arthritis
o Grading System for Pain
- CHRONIC: Infections, neoplastic conditions, Metabolic
0 No Pain
conditions, Arthritides; OA & RA (Chronic >6wks)
1 Pain ONLY with STRENUOUS activity
2 Pain EVEN with MODERATE activity
OTHER PRESENTING SYMPTOMS:
3 Pain EVEN with MILD activity
- Stiffness
- Swelling 4 Pain EVEN at REST
- Weakness 5 Pain which results with LOSS OF
- Heaviness SLEEP
- Difficulty moving

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LECTURE: MUSCULO-SKELETAL SYSTEM AD ASTRA PER ASPERA
 EXTRA-ARTICULAR MANIFESTATION ethambutanol: inc uric acid levels
- Constitutional: fever, malaise, fatigue predisposing patients to
- Skin: rash, vasculitis, alopecia - gout attacks
- Mucous membrane lesions: oral, genital TENDON - Quinolones, glucocorticoids,
- Urethritis: discharge and dysuria RUPTURE/TENDINITI - isoretinoin
- Raynaud’s phenomenon: triphasic color change (French S
Flag Sign); manifests in the digits especially when cold, (+)
antiphospholipid syndrome, autoimmune disease (SLE) REVIEW OF OTHER RELEVANT INFORMATION
- Paresthesias, hypoaesthesias - Personal/Social History
- Ocular symptoms: iritis, uveitis, conjunctivitis o Smoking: risk factor for RA, Avascular necrosis
- Sicca syndrome: keratoconjunctivitis, xerostomia o R-OH
- GIT symptoms: dysphagia, pain, and diarrhea, weight loss o Sexual History/Practices: example: reproductive age
- Pleuropericardial symptoms: pain, dyspnea group patient with monoarticular swelling, can be
- Myalgia: pain, tenderness, and weakness septic arthritis from gonococcal infection. Reiter’s: old
- Neurologic symptoms: CTS, headaches, visual term for reactive arthritis: triad of urethritis, uveitis,
disturbances; patients with giant cell arteritis arthritis
o Family History
FUNCTIONAL HISTORY
- Social Function: Marital Status, ability to interact with QUESTIONS FOR THE CLINICIAN TO ADDRESS
friends, leisure - Is the problem regional or generalized, symmetric or
- Emotional function: ability to cope with anxiety, asymmetric, peripheral or central?
frustration, and depression - Is it acute, subacute, or chronic problem? Is it progressive?
- Financial function: if needs financial assistance - Do symptoms suggest inflammation, damage to MSK
- Physical function: ability to stand, walk, dress, undress, structures?
toileting, bathing, feding, duties in home and workplace - Is there evidence of systemic process? Are there associated
(ADLs: activities of daily living) systemic features?
- Is there an underlying medical disorder which may
CRITERIA FOR CLASSIFICATION OF FUNCTIONAL STATUS IN RA predispose to specific rheumatologic problem?
CLASS 1 COMPLETELY able to perform usual ADLs (self- - Has there been functional loss/disability?
care, vocational, and avocational) - Is there a family history of a similar or related problem?
CLASS 2 ABLE to perform usual self-care and vocational
activities, but LIMITED in avocational activities RAPID MSK SCREENER EXAMINATION
CLASS 3 ABLE to perform usual self-care activities, but - General Questions
limited in vocational and avocational activities o Have you had any pain or stiffness in your muscles,
CLASS 4 LIMITED in ability to perform usual self-care, joints, or back?
vocational, and avocational activities o Can you undress yourself completely without any
- usual self-care activities include: dressing, feeding, bathing, difficulty?
grooming, and toileting. Avocational (recreational and/or o Can you walk up and down the stairs without
leisure) and vocational (work, school, homemaking) difficulty?
activities are patient-desired and age- and sex- specific.
THE FOUR PRINCIPLES
DRUG HISTORY - Inspection
DRUG-INDUCED MSK CONDITIONS o examine visually, to look
ARTHRALGIA - Cimetidine, Quinolones, o ex: swelling, erythema, skin lesions (rashes, nodules),
- Nicardipine, Vaccines, Rifabutin discoloration, muscle atrophy
MYALGIAS/MYOPAT - Glucocorticoids, Statins, Fibrates, o Deformities: Bouchard’s Nodules: over PIP,
HY Interferons, r-OH, Cocaine, Heberden’s Nodules: over DIP (B before H)
Quinolones, o Contractures, Articular Subluxations, Malalignment
- Cyclosporine - Palpation
GOUT - Diuretics, aspirin, cytotoxics, o examine by touch; to feel warmth (use dorsum of
cyclosporine, R-OH, moonshine, hand), tenderness, crepitations (popping
between joints)

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LECTURE: MUSCULO-SKELETAL SYSTEM AD ASTRA PER ASPERA
 - Range of Motion COMMON CAUSES OF SHOULDER PAIN:
o test the distance a joint can move INTRINSIC
- Function - PERIARTICULAR DISORDERS
o ability to successfully perform the tasks and roles o Rotator Cuff Tendinitis (SITS muscles): impingement
required for daily living syndrome
o Calcific tendinitis
IMPORTANT PHYSICAL SIGNS OF ARTHRITIS o Rotator cuff tear
- Swelling o Bicipital tendinitis: long head biceps tendon
o from intra- or extra-articular structures impingement along the bicipital groove
o loss of normal landmarks or contours o Acromioclavicular arthritis
o always compare same joints on both sides - GLENOHUMERAL DISORDERS
o palpation: if chronic, feels doughy or boggy in o Inflammatory arthritis
consistency o Osteoarthritis (OA)
- Tenderness o Cuff arthropathy
o unusual discomfort on palpation, note for wincing and o Septic arthritis
facial expression of patient o Glenoid labral tears: glenoid labrum holds negative
o helpful in localization of pain source (intra- or extra- pressure against the humeral head to stabilize it with
articular) the glenoid cavity
- Limitation of ROM (LOM) o Adhesive Capsulitis (Frozen Shoulder)
o one should know the normal end feel and ROM per o Glenohumeral Instability
joint assessed
o always compare affected with unaffected; assess EXTRINSIC
unaffected first to determine normal range - REGIONAL DISORDERS
o active then passive ROM o Cervical Radiculopathy
- Crepitation o Brachial Neuritis
o it is the palpable or audible grating or crunching o Nerve Entrapment syndromes
sensation produced by motion (similar to cracking of o Sternoclavicular arthritis
knuckles) usually from rubbing of bony surfaces - MISCELLANEOUS
o may or may not have discomfort during movement o Reflex sympathetic dystrophy (RSD)
- Deformity (see inspection) o Fibrositis
- Instability o Neoplasm
o feeling of buckling of joints, occurs when a joint has o Gallbladder disease
an increased range of motion or movement in any o Splenic trauma
plane o Subphrenic abscess
o Subluxation: partial displacement of articular surface o Myocardial infarction
(can be seen in chronic stroke patients’ shoulder) o Thyroid disease
o Dislocation: complete displacement of articular o Diabetes Mellitus
surface (commonly seen in trauma) o Renal osteopathy

MUSCULOSKELETAL PHYSICAL EXAMINATION SPECIFIC SHOULDER CONDITIONS

TEMPOROMANDIBULAR JOINT (TMJ)
- Condylar synovial joint
- Landmark: 0.5cm anterior to the external auditory meatus
(EAM); confirm by opening and closing the jaw: should feel
like going out when opening and going in when closing.
Movement should be similar and at the same time.
- Inspection: swelling, redness, deformities
- Palpation: tenderness, crepitations
- ROM: protrusion, retraction, lateral movement
SHOULDER (GLENOHUMERAL) JOINT
- Multi-axial spheroidal joint with spherical head and shallow
glenoid cavity; potential unstable (ball and socket joint)
- ROTATOR CUFF TENDINITIS
o Composed of the SITS muscles: Supraspinatus,
Infraspinatus, Teres Minor, Subscapularis
o Degeneration of the tendon calcification
o Most common affected: Supraspinatus tendon
o Sx appear with repeated arm elevation activities
o Pain: located anterior and lateral and may radiated to
the lateral deltoid sleep interference
o Painful arc: 70-110 degrees of abduction
o (+)Impingement Test

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 o Upon movement, there is limitation of motion
accompanied by pain
o Pain is generalized and referred to the upper arm,
back, & neck
o Self limiting condition, unless there is an underlying
cause
o Common in diabetics, those with thyroid disease, and
parkinsonism

ELBOW JOINT
- Synovial joint, Composed of three bony articulations:
- CALCIFIC TENDINITIS o Humeroulnar: Hinge joint
o Deposition of Calcium salts, primarily Hydroxyapatite, o Radiohumeral
within or surrounding a tendon o Proximal radioulnar
o Due to ischemia or tendon degeneration - Movements:
o Pain: Impingement upon overhead activity o Flexion/Extension
- BICIPITAL TENDINITIS o Pronation/Supination
o Long head of biceps tendon course through the
bicipital groove, being impinged by the transverse SPECIFIC ELBOW CONDITIONS:
humeral ligament upon excessive movement - CUBITUS VALGUS
o Shoulder pain radiates down the biceps and into the o Forearm is angled
forearm away from the body
o Pain occurs with overhead activity and/or with lifting o Carrying angle is
heavy objects <170 degrees
o Limited motions: Abduction and External Rotation o *vaLgus: the upper
(AbER) of the shoulder extremity looks like
an “L”
YERGASON’S TEST - CUBITUS VARUS
o Forearm is deviated towards midline of the body
- OLECRANON BURSITIS
o fluid accumulation over the olecranon bursa
o s/sx: pain, tenderness, difficulty in movement
- ULNAR TUNNEL SYNDROME
o impingement of the ulnar nerve along it’s course at
the ulnar groove located at the lateral side of the
distal part of the humerus
o causes pain, paresthesia, sometimes weakness on the
5th digit and ulnar half of ring finger and palm
- LATERAL EPICONDYLITIS (TENNIS ELBOW)
*elbow flexion with pronation of the forearm o pain on the lateral aspect of the elbow and worsens
with resisted wrist extension
- SUBDELTOID BURSITIS o originates from the extensor tendon origin
o Bursa is located between the acromion process and o most common affected: ECRL & ECRB tendons
the head of the humerus at the tip of the shoulder o backhand injury
o Visible during inflammation (looks like swelling)
o S/sx: pain, swelling, tenderness on the tip of the
shoulder
- ADHESIVE CAPSULITIS
o Frozen Shoulder
o Joint capsule decreased in size; diffused inflammatory
synovitis with subsequent adherence of the capsule
and loss of joint volume

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 - MEDIAL EPICONDYLITIS (GOLFER’S ELBOW) NERVE INJURIES
o pain on the medial - CLAWHAND
aspect of the elbow o Hyperextended MCPs and PIPs and DIPs flexion
and worsens with o Seen in Brachial Plexus or Ulnar
flexion of the wrist Nerve injuries
o affects the wrist flexor o *to help remember:
tendons ClUmbricals: Claw Hand-Ulnar
o forehand injury Nerve Injury (sometimes
median)-Affects Lumbricals
HANDS - HYPOTHENAR ATROPHY
- Anatomy: o common in ulnar nerve injuries
o Distal Interphalangeal Joints (DIP)
o Proximal Interphalangeal Joints (PIP)
o Metacarpophalangeal Joints (MTP)
o Carpometacarpal Joints (CMC)
o Wrist Joint: Radiocarpal, Intercarpal, Distal - WRIST DROP
Radioulnar joints o pronated wrist drop from wrist
extensor weakness
o caused by injury to the radial
nerve/radial nerve palsy
- CARPAL TUNNEL SYNDROME (CTS)
o Median nerve palsy,
usually from compression
of the median nerve in the
flexor retinaculum
o there can also be
numbness and tingling
sensation on the median
WRIST nerve distribution in the
- composed of the radius, ulna, and carpals hand
- True wrist: radiocarpal joint - TINEL’S SIGN
- Movements: flexion, extension, circumduction, abduction o examiner taps over the
median nerve in the wrist
SPECIFIC WRIST & HAND CONDITIONS: using a neurohammer and
- Nerve Problem it produces a tingling
o Brachial Plexus Injury sensation along the
o Radial, Ulnar, Median nerve injuries median nerve distribution
- Infection or Metabolic Disease o (+) test: numbness or
o Tetanus tingling sensation is present along the tested nerve
o Cellulitis - PHALEN’S TEST
o Dupuyten’s contracture o examiner flexes the patient’s wrists and holds them
o Gout together for about a minute.
- Inflammatory Arthritis o (+): tingling sensation in the median nerve
o Rheumatoid Arthritis distribution
o Psoriatic Arthritis o another test that can be
o Osteoarthritis used is Prayers/Reverse
- Tendinitis/Tenosynovitis Phalen’s Test: same
o Stenosing tenosynovitis (Trigger finger) positive results
o De Quervain’s tendinitis
- Congenital Deformities
- Others - THENAR ATROPHY
o due to median nerve damage

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 - BOUTONNIERE DEFORMITY
o Chronic swelling weakens supportive structures
o Extensor tendon slides into the palmar aspect of the
finger
o PIP joint is flexed, DIP joint is hyperextended
- SWAN NECK DEFORMITY
SECONDARY TO INFECTION OR METABOLIC DISEASES o Chronic swelling at the PIP joint cause displacement
- CARPAL SPASM and pulling of the extensor tendon
o thumb is flexed into the o PIP joint is hyperextended and DIP joint is flexed
palm and wrist, MCPs o Contracture prevents normal mobility of a joint from
flexed, IP joints are abnormal formation of fibrous tissue
hyperextended; occurs in *MUST KNOW
tetany PIP DIP
- TOPHACEOUS GOUT Boutonniere Flexed Hyperextended
o (+) tophi: uric acid crystal Swan Neck Hyperextended Flexed
o deposition in different soft tissues; white- **Additional notes: Mallet Finger, Extended MCPs, PIPs, Flexed
yellow/chalky appearance DIPs
o Podagra: initial findings seen at the 1st MTP joint
- ULNAR DEVIATION/ULNAR DRIFT
o there is destruction of supporting structures from
chronic inflammation
o the long axis of the fingers deviate or drift towards the
ulnar side from the MCP joints
- CELLULITIS o presence of chronic synovitis may lead to atrophy of
o Swelling, warm, tender, and surrounding muscles, tendons, and ligaments; there
erythematous can also be rheumatoid nodules present

- DUPUYTREN’S CONTRACTURE
o Chronic, fibrotic process involving the palmar fascia of
one or both hands contracture of the ring and little
fingers
o Can be hereditary, m/c in diabetic patients and in
those with metabolic conditions such as thyroidism - ARTHRITIS MUTILANS
o severe destruction of hand
joints
o common in severe and
chronic RA & OA
o there is MCP subluxation;
“telescoping of fingers”
o *always remember in history
taking: if a patient is complaining of hand pains,
INFLAMMATORY AND NON-INFLAMMATORY ARTHRITIS determine if s/he has RA. If RA is not
- Osteoarthritis determined/diagnosed at an early stage, it could lead
- Psoriatic Arthritis to destruction of hands—loss of function inability to
- Rheumatoid Arthritic Conditions: perform ADLs.
- PIANO KEY SIGN
o done by Palpation; there is depression when the ulnar
styloid is pressed down.

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 o the examiner presses down on the ulnar styloid and - OSTEOARTHRITIS
when pressure is removed, it bounces back from a o CMC squaring
lowered position—as if like a piano key o Bouchard’s Node: bony
o (+) test may suggest weakness of ligaments and enlargement of PIP joints
tendons, particularly the TFCC, weakened by synovitis o Heberden’s Node: bony
of arthritis enlargement of DIP joints
- EXTENSOR TENDON RUPTURE o Nodes have a bony
o there is an inability to extend the fingers actively but consistency upon palpation (vs PSA node which is
able to be moved passively boggy on palpation)
o due to bony changes and chronic inflammation at the
wrist INFLAMMATION IN THE TENDONS/TENDON SHEATHS
- STENOSING TENOSYNOVITIS (TRIGGER FINGER)
o presence of a painless nodule in the flexor tendon in
the palm of the hand near the head of the metacarpal
o finger is able to extend with a palpable and audible
snap that is also present in
flexion; maximum
tenderness on point of
nodule
o “Trigger Finger”: Third &
Fourth fingers commonly
affected

- DE QUERVAIN’S TENOSYNOVITIS
o presence of pain in the lateral aspect of the wrist and
thumb
o there is inflammation in the tendon sheath of the
Extensor Pollicis Brevis and of the Abductor Pollicis
Longus (AbdPolLo, ExPoBre)
*The hand joints become inflamed in RA with a boggy, doughy - POSITIVE FINKELSTEIN TEST
texture. In chronic cases, there is an ulnar drift with wasting of
o patient adducts the thumb towards the palm and the
dorsal intrinsic muscles
rest of the fingers flex, overlapping the thumb. The
patient then ulnar deviates the wrist.
- GRIP STRENGTH TEST
o common in patients with overused thumbs: texters
o the patient grasps 2-3 fingers
from each of the examiner’s
CONGENITAL ANOMALIES
hands as much as s/he could - POLYDACTYLY
o determines and checks muscle
o “Supernumerary Fingers”
weakness and wasting o Associated with certain syndromes
- PSORIATIC ARTHRITIS
o presents with DIP swelling, may also involve the PIPs,
MCPs
o RA doesn’t have DIP swelling
- DACTYLITIS
o “sausage digit”; swelling of
the entire digit/finger - SYNDACTYLY
o is not present in patients with o “Webbed Fingers”: fusion of two or more digits
RA/OA - SCLERODACTYLY
- ONYCHOLYSIS o flexion deformity from tight skin: there is excessive
o nail changes associated with PSA fibrosis in the skin of patients, very hard upon
o differentiate from palpation of the digits
Onychomycosis: caused by
fungal infection

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 o upon inspection, digital pits can also be seen. This is INSPECTION
from decreased blood supply to the digits ischemia - STANDING
ulcer formation o Inspection from behind:
o **In patients with  straight spine
dermatomyositis, there is  both iliac crests on same level
weakness of the  normal muscle bulk
extremities, especially of o Inspection laterally:
the proximal muscle  check for loss/presence of normal cervical and
groups with associated lumbar lordosis
rash and sometimes,  alteration of normal mild thoracic kyphosis
dilated capillaries o Inspection anteriorly:
 check for swelling, abnormal position, skin
OTHER CONDITIONS changes over the sternoclavicular and
- Subluxation: partial/incomplete joint displacement acromioclavicular joints
- Dislocation: joints are completely displaced and no longer PALPATION
in contact with each other - Muscle spasm
- Mallet Finger - Tenderness/Point Tenderness
o associated with trauma, not associated with RA - Bony defect
o even with active extension effort, the DIP remains in
flexion

- Nail Clubbing *memorize this picture ©LizRch

o inspection findings
o can be an indication that patient REFERRED PAIN:
has serious disease such as in - Felt in more distant sites, innervated at approximately the
cardiopulmonary conditions same spinal nerve levels as the diseased structure.
- Schamroth’s Test - Pain gradually becomes more intense and may seem to
o In normal conditions, the distal phalanges of radiate or travel from the initial site.
corresponding fingers of opposite hands are directly - May be felt superficially or deeply, but is usually localized
opposed: the fingernails of the same finger on (Bates)
opposite hands are placed against each other, nail-to- - Example: When a patient comes in and c/o back pain, the
nail, forming a small diamond-shaped “window” pain may not be due to neuromuscular causes, but due to
between nail beds visceral/referred pain. Always check your inspection and
o Positive test: no window present = clubbing palpation findings.
- **In area 4, patient may c/o back pain, but upon inspection,
there is no swelling.
o Upon palpation, no tenderness noted.
o Back pain may be then due to referred pain from the
pancreas, PUD, or from aortic aneurysm
- **In area 6, PE findings are normal but still will pain, there
SPINE AND SACRUM is referred pain and may originate from the hip and not the
- In performing examination of the Spine, it should be done back.
in:
o Standing
o Lying: Supine/Prone
o Sitting

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 CERVICAL SPINE CONDITIONS o irritation of cervical roots painful spasm of neck
- CERVICAL SPONDYLOSIS (CERVICAL OSTEOARTHRITIS) muscles with pain on the shoulder and lateral aspect
o Intermittent neck pain accompanied by stiffness and of the arm
radiating pain towards shoulders or the occiput
o there is degeneration of the vertebrae  shortening KEY SYMPTOM: BACKACHE
of the intervertebral disc and nucleus pulposus; - spinal regions below C7
osteophyte formation ACUTE CHRONIC
- if with Cervical Radiculopathy, (+)Spurling’s Test - Fractures - Osteoporosis
- Differentiate from Spondylolysis and Spondylolisthesis - Dislocations - Pott’s Disease (TB
o Spondylolysis: injury in the Pars Interarticularis - Herniated disc of the Spine)
o Spondylolisthesis: Anterior gliding of the vertebra - Torn ligaments - Neoplasm
over another CAUSES - Muscle strain - Herniated disc
- Ankylosing
Others: spondylitis
- Subarachnoid - Osteoarthritis
Hemorrhage - Fibromyalgia
- Tetanus
- *if pain is too
sudden, consider - Esophageal CA
the following - Peptic Ulcer
- SPURLING’S TEST REFERRED conditions: Disease
o Patient’s neck is put to hyperextension and lateral PAIN - Angina Pectoris - Aortic Aneurysm
flexion - Acute Pancreatitis
o Examiner then puts a downward pressure on the head - Pneumothorax
and pressure is held for a few seconds - Dissecting
o Positive when there is radiating pain on the upper aneurysm
extremity of the side being tested (where patient’s - Fibromyalgia: example: a female patient comes in c/o
neck is laterally flexed) generalized pains, not relieved with pain relievers and is
o test elicits narrowing of the vertebral foramina where easily fatigued.
nerves pass through: if there are osteophytes present o All tests and PE findings are normal; in Fibromyalgia,
in the inner surface of the foramina, there will be brain’s processing is the problem.
further narrowing and may cause impingement of the o It is considered as neuropathic pain wherein light
cervical plexus touch can trigger points and patient will feel extreme
- WHIPLASH INJURY pain.
o from sudden forceful hyperextension of the neck with o Even if the stimulus is not painful, the patient will
flexion recoil identify it painful.
o most common cause: MVAs o To test for fibromyalgia, apply 4kg weight (this weight
is enough to cause nail bed blanching) on trigger
points patient will feel pain but r/o other diseases

LOW BACK PAIN

**Common causes (must know):
- Mechanical Back Pain
- Inflammatory Back Pain
- Neurogenic Back Pain
- Back Pain of Systemic Origin
o injury can lead to spinal cord injuries (SCIs) and
- Psychogenic Back Pain
sometimes traumatic brain injury (TBIs)
- CERVICAL SYNDROME
MECHANICAL BACK PAIN
o usually proceeded with minor trauma such as
- Most common type of pain seen in clinical practice
performance of sudden movements
- pain is related to movement and exercise with exacerbation
of prolonged standing or sitting, and is relieved by rest

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LECTURE: MUSCULO-SKELETAL SYSTEM AD ASTRA PER ASPERA 15
 - spinal osteoarthritis, postural impairment, small muscle or
ligament distensions: m/c cause
INFLAMMATORY BACK PAIN
- pain worse at night and in the morning, usually
accompanied by prolonged morning stiffness; triggered by
immobility
- relieved by exercise/movement
- most common cause: Seronegative Spondyloarthropathies
- common in the young male population (Ankylosing
spondylitis)
NEUROGENIC BACK PAIN
- pain is mechanical in origin but radiates below the knee
following a certain dermatome (L5 or S1), with paresthesia
- exacerbated by valsalva maneuver (straining or coughing)
- tests for sciatica/sciatic nerve stretch tests are usually
positive
- most common cause: herniated disc, osteophytosis,
fractures, neoplasm
- Paresthesia: abnormal tingling/pricking sensation,
described as “pins and needles”, “parang may kuryente”,
caused by impingement or damage to the peripheral nerves
SCIATIC STRETCH TEST
*pain will originate from the back to the lower extremity being
tested
BACK PAIN OF SYSTEMIC ORIGIN
- rhythm of pain varies but usually not relieved when lying
down
- there is a clearly defined area of tenderness on examination
- Pain may be referred from the intra-abdominal viscera or
reflect serious local bony or disc pathologies such as
metastases or infection
- associated with other systemic manifestations such as:
fever, weight loss, or abdominal pain (red flags of back pain)
- **other red flags: elderly patients, pain not relieved by
analgesics, pain worse at night
CLINICAL DIAGNOSIS B PHYSICAL DIAGNOSIS
LECTURE: MUSCULO-SKELETAL SYSTEM
PSYCHOGENIC BACK PAIN
- pure psychogenic LBP is rare
- manifestations are exaggerated, especially in cases of
depression, labor disputes, secondary gain, or manipulative
personality
- there are multiple, spurious complaints such as migratory
paresthesia, cold sensation on the back, intense pain upon
superficial touch
- unremarkable neurologic examination
- to consider fibromyalgia
- *in patients experiencing chronic depression, they feel a lot
of pains: true type of pain. Depression is addressed prior to
back pain. In some cases, patient won’t have any pain after
being given antidepressants
THORACOLUMBAR SPINE CONDITIONS
- KYPHOSIS
o accentuated thoracic vertebrae concavity
o causes: faulty posture, ankylosing spondylitis,
osteoporosis
o examples of exaggerated kyphosis: Gibbus,
Dowager’s Hump
- SCOLIOSIS
o Abnormal lateral deviation of the spine
o Dextroscoliosis: convexity is facing/on the right side
o Levoscoliosis: convexity is facing/on the left side
o In some cases, there is a primary curve and if it is not
treated, compensatory curves develop to fix the
curvature leading to S-shaped curves
o Upon forward bending assessment, there is increased
chest deformity in a fixed kyphosis that can aggravate
cardiopulmonary conditions
- GIBBUS
o Angular curve caused by collapse of
one or more contiguous vertebrae
o Caused by: compression fracture,
metastatic carcinoma, Pott’s disease
- LORDOSIS
o accentuated posterior concavity of the
lumbar spine
o upon inspection, “parang ma-pwet”
o *Dowager’s Hump
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- INFECTIOUS SPONDYLITIS
o example: Pott’s disease
o there is collapse of the anterior portion of the
vertebra (similar to Gibbus Deformity)
o pain and tenderness at the site of lesion
o can manifest as paraplegia or psoas abscess
o Psoas abscess: (+) heel-landing test or jar test
- ANKYLOSING SPONDYLITIS
o Back stiffness with limitation of motion
o Initial symptom: Sacroilitis
o HLA-B27 antigen
o (+) Schober’s Test
o pain is exacerbated with standing (promotes
compression further movement of the slipping
vertebra), standing also promotes further lordosis as
the center of gravity moves anteriorly (PE: increased
lordosis)
o pain is relieved with rest, such as lying down of sitting
where the hips flex promotes flexion of the lumbar
vertebra
o **may help understand mechanism of action ng pain
- PROLAPSED INTERVERTEBRAL DISC
o there is degeneration and herniation of the nucleus
pulposus, the annulus fibrosus ruptures and the fluid
nucleus pulposus goes out and may cause pain upon
hitting the spinal roots
o there is a sudden onset of back pain with
radiculopathy, neuropathic type of pain is felt by the
patient

o *patient stands erect with feet together. Place a mark

on the spine at the lumbosacral junction. (at the level of
L5 spinous process or centerpoint where an imaginary
EXAMINATION FOR HERNIATED DISC
line between PSIS intersects the spine, iliac crests or
SCIATIC NERVE STRESS TEST:
dimples of the back are used) and a 2nd mark 10cm
- STRAIGHT LEG RAISING (SLR)/LASEGUE’S TEST
superior to the 1st. The patient then bends forward
o patient is supine and the examiner lifts the leg with
maximally, trying to touch their toes. (note that some
the knee in extension (the affected limb is raised first)
patients have tight hamstrings and can’t reach the toes)
o (+): pain would be felt at 30-60 degrees of hip flexion
o *normal distance between the two marks increases by
o *2017 notes: Lasegue’s test = in performing the test,
greater or equal to 5 cm. If the distance is <4cm, there is
the knee is flexed initially perform SLR then knee
restriction of mobility may have AS (De Gowin’s)
extension

- SPONDYLOLISTHESIS
o anterior slippage of the L5 vertebra over the S1
o there is low back pain (LBP) associated with pain
radiating towards the legs/buttocks (remember
lumbosacral plexus)

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 - CROSSED (REVERSE STRAIGHT LEG RAISING) - THOMAS TEST
o patient is in supine position and the examiner lifts the o Indicates fixed flexion
unaffected leg with the knee held in extension deformity of the hip
o (+) test when pain is elicited in the contralateral o the patient is in supine
leg/affected limb position and assumes a knee-
- MODIFIED STRAIGHT LEG RAISING/BRAGGARD’S TEST to-chest position on one leg
o modified SLR: there is additional dorsiflexion of the and the other leg remains
foot after SLR extended
- FEMORAL NERVE STRETCH TEST o (+) test: the contralateral (hip not being tested) flexes
o the patient is in prone position and the knee is flexed without knee extension
maximally; (+) test: pain in the leg being tested (pain - ANVIL TEST
anteriorly, remember femoral nerve innervation; L2- o indication for early hip joint
L4) diseases
o the patient lies in supine
HIP JOINT position, the leg is raised with
- Articulation of the femoral head with the acetabulum the knee extended and the
- the hip is a synovial joint examiner hits the calcaneus
- Movements: Flexion, Extension, Adduction, Abduction, using their fist
Internal and External Rotation - TRENDELENBURG’S SIGN
o the patient assumes a one leg
CAUSES OF HIP JOINT PAIN: standing/flamingo-like position.
- Muscle strain o if (+), the hip on the non-stance leg
- Bursitis will drop. This indicates that the
- Osteonecrosis gluteus medius muscle on the stance
- Dislocation leg is weak
- Subluxation
- Osteomyelitis LOWER EXTREMITIES
- Fractures - composed of the knee, ankle, and foot joints
- Herniated Intervertebral Pain KNEE
- movements: flexion/extension
SPECIFIC HIP CONDITIONS - largest and most complicated joint in the body
- Ischiogluteal Bursitis - modified hinge-type joint
o there is pain on the area of the buttocks that is
aggravated by sitting, making it impossible to tiptoe DISORDERS GENERATING KNEE PAINS:
o (+) tenderness on the ischial tuberosity ANTERIOR MEDIOLATERAL POSTERIOR
- Acute Suppurative Arthritis of the Hip
Prepatellar Meniscal Tibial neuritis
- Tuberculous Arthritis
bursitis abnormality
- Osteoarthritis
Patellar tendon Posterior cruciate
- Avascular Necrosis
disorders Tibiofemoral arthritis trauma
Patellofemoral Baker’s cyst
MANEUVER FOR HIP PATHOLOGY
arthritis/overload
- PATRICK’S / FABERE’S TEST
o FABERE: Flexion,
PHYSICAL SIGNS
Abduction, External
- Valgus Deformity
rotation of the hip (de-
- Varus Deformity
kwatro sitting)
- Genu recurvatum
o this test is passive and is
- Fixed flexion
performed while the
MANEUVERS
patient is in supine or
- Bulge sign
seated
- Balloon/ballottement of the patella
o positive test: pain upon
- Patellofemoral grinding test
positioning; indicates hip disease or iliopsoas
(+): Osteoarthritis
tightness

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 SPECIFIC CONDITIONS AFFECTING THE KNEE: - Push the lower leg towards the midline and the thigh
- GENU VARUM/BOW LEGGED laterally  producing a varus force
o predominantly affects the medial compartment of
the knee VALGUS STRESS TEST
o the medial compartment collapses making the - tests the medial collateral ligament stability
lateral - apply valgus stress with the knee in flexion
o compartment the dependent part varus deformity - (+): separation of tibia from femur
o such that in early OA, the medial compartment of - if still (+) upon knee extension, the posterior cruciate
the knee is affected. ligament might also be torn
o OA more commonly presents with Genu Varum
deformity
- GENU VALGUM/KNOCK KNEES
o predominantly affects the lateral compartment of
the knee
o more commonly presents in RA conditions
- BAKER’S CYST
o cysts found at the popliteal area, indicative of
osteoarthritis. When ruptured, there is a severe
posterior leg pain.
MILD (1ST <5mm separation
o Positive Ballotement or Bulge Sign: the fluid should
DEGREE)
be taken out. Physical characteristics of the synovial
MODERATE (2ND With marked local tenderness between 5-
fluid gives differential diagnoses.
DEGREE) 10mm
 Yellow Fluid: (+) pus, possible septic arthritis
SEVERE (3RD >10mm
 Red Fluid: trauma
DEGREE)
DEPENDING ON THE CLINICAL SCENARIO, SYNOVIAL FLUID IS
- ANTERIOR DRAWER TEST
ANALYZED FOR:
o tests stability of the anterior cruciate ligament
- Cell count and differential count
o commonly performed test in ACL patients
- Crystals: if gout and pseudogout is suspected
o less satisfactory test
- Culture and sensitivity: if septic arthritis
o the patient is supine and the knee is flexed at 90
- Cytology: malignancy
degrees, the upper
part of the lower leg is
Normal Non- Inflam Septic Hemorr
pulled anteriorly.
Inflam mator hage
o a positive test is seen
matory y
when the lower leg is
CLARITY Transpa Transpa Transl Opaque Bloody
easily moved, feeling
rent rent ucent
that the leg is lax
COLOR Clear Yellow Yellow Dirty Red
- POSTERIOR DRAWER TEST
Yellow
o tests posterior
VISCOSITY H H L Variable Variable
cruciate ligament
stability
TESTS FOR KNEE CONDITIONS
o instead of pulling the lower leg anteriorly, it is being
TEST FOR STABILITY:
pushed posteriorly
- Patient is in supine and the knee is flexed at 20 degrees
o a positive test is seen when the lower leg is easily
- The examiner stabilizes the patient’s foot and ankle in
moved, feeling of laxity when it is being moved
between his arm and the chest
- The examiner then applies varus or valgus stress
ANKLE AND FOOT
VARUS STRESS TEST MOVEMENTS:
- tests lateral collateral ligament stability Tibiotalar function Subtalar function
- the knee is held firmly by internal face with one hand and Dorsiflexion/Plantarflexion Inversion/Eversion
the lower leg with the other, keeping the knee at about 20-
30 degrees flexion

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 ANKLE o the 1st MTP joint has a bony feeling upon palpation
- transfers vertical to horizontal weight bearing and rarely vs Hallux valgus, more of boggy
deteriorates
- swelling alone the lateral and medial malleolus is not a true
synovitis
- synovium is not present over the malleolus

FUNCTIONAL ANATOMIC UNIT OF THE FOOT

FOREFOOT MIDFOOT HINDFOOT
5 MTPs 5 tarsal bone and Talus
1 IP articulations Calcaneus
4 DIPs & PIPs Navicular and
subtalar joints - PLANTAR FASCIITIS
o there is pain along the medial
LOCATION OF PAIN IN THE FOOT plantar aspect of the heel,
FORE MIDFOOT HIND ANKLE DIFFUSE without any history of trauma
FOOT FOOT o the plantar fascia is maximally
RA X X X stretched, producing tension
OA X X points throughout the foot
FASCIITIS/TEN X X o it is most painful upon taking
DINITIS the first step in the morning,
GOUT/ PSEUDO X X upon waking up/getting up
GOUT from the bed.
o associated with pes planus, pes cavus, obesity
SPONDYLOART X X - PES PLANUS
HROPATHY o flat foot; there are two types:
INFECTION X X flexible and non-flexible.
BONE INJURY X X o Flexible: flatfoot disappears
NERVE INJURY X when the foot is not
REFLEX X weightbearing.
SYMPATHETIC o Non-flexible: flatfoot remains
DYSTROPHY even if the foot is not
SYNDROME weightbearing
(RSDS) o there is a collapse of the medial
longitudinal arch and the
VASCULAR X
navicular bone is lowered from
TUMOR X
its normal position
- PES CAVUS
SPECIFIC CONDITIONS OF THE FOOT:
o high in step/high medial
- HALLUX VALGUS (BUNION)
longitudinal arch
o results as the hallux (big toes) laterally deviates
- CORN AND CALLUS
from a medially deviated MTP joint.
o Corn: hyperkeratosis on the dorsum of the foot,
o a painful bursa develops over the medial MTP joint,
painful
especially when it is compressed.
o Callus: hyperkeratosis on the soles of the foot from
o has a genetic component but aggravated by
repeated friction and pressure; not painful
shoewear, especially pointed or narrow shoes
*there is also Hallux Varus but is usually a complication from
surgery
- HALLUX RIGIDUS
o there is a limitation of movement about the 1st MTP
joint because of a proliferative osteophyte
formation at the end of the metatarsal head
Notes from Lecture Handout and MEDS PTRP Trans

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