- range of motion (active/passive), swelling, tenderness, heat, redness, crepitation, deformities, symmetry of involvement, condition of surrounding skin/tissues, muscular strength

Characteristics of Musculoskeletal Exam

- creates a boggy feeling to the joint

Synovial membrane swelling

- affects joints in a symmetric fashion

Rheumatoid arthritis

- hinge and gliding joint

- lies anterior to external auditory meatus

- palpated by placing the index finger into auditory canal w/ thumb externally over joint as pt opens mouth

- Dx produces jaw, neck, ear or head pain that worsens with jaw movement

- mostly affects women 30-49

Temporomandibular Joint (TMJ)

- inflammation results in tenderness, swelling, and heat

- may be involved in rheumatoid arthritis

Sternomanubrial joint

- inflammatory process of costochondral joints that causes localized pain and tenderness

- more than 1 site affected in most cases (2nd-5th)

- benign cause of chest pain

- palpably tender as "trigger point"

Costochondritis

- least commonly dislocated joint

- car accident nearly half of all dislocations

- most dislocations are anterior where clavicle is pushed forward

- posterior dislocations endanger great vessels, trachea, lungs, and esophagus

- may be infected in IV drug users with septic arthritis (Pseudomonas aeruginosa)

Sternoclavicular joint

- common site for osteoarthritis in middle age

- painful and cause difficulty using the shoulder in everyday activities

- w/ pt arm across front of chest, palpate directly

Acromioclavicular joint

- supraspinatus, infraspinatus, teres minor, subscapularis

- responsible for stabilizing head of the humerus in the glenoid fossa

- required to help deltoid abduct the arm

Rotator cuff

- pectoralis major, teres major, latissimus dorsi

Adductors of shoulder

- results of chronic raising of the arm and the production of rubbing or pinching action on the subacromial and subdeltiod bursa causing inflammation

Impingement syndrome

- generalized aching of the shoulder, swelling, tenderness, warmth in antero-lateral shoulder

- pain may radiate into neck and down to elbow

- aggravated by abduction of the shoulder, lying on it

- sharp pain when "reaching in back pocket"

Symptoms of Impingement Syndrome

C5

- palpation w/ thumb anterioraly over bicipital groove for tenderness, swelling or crepitus when pt's arm is rotated externally tests for this

- pain may be elicited with resistance to supination

Bicipital tendinitis

- usually caused by chronic degeneration associated with acute minor trauma

- most tears in supraspinatus in older people

- tendons have poor blood supply, worse with age

Rotator cuff tears

- angle of passive or active abduction in which pain is felt with rotator cuff inflammation

60-120 degrees

- muscle that is used to initiate abduction (0-90 degrees)

Supraspinatus

- painful condition of the shoulder that results from severe inflammation of the joint capsule

- reduced passive AND active ROM

- may follow an injury but frequently develops w/o warning

Frozen shoulder (adhesive capsulitis)

- produces pain localized to the shoulder

- may have rheumatoid or osteoarthritis

- often localized anteriorly over acromioclavicular joint and accompanied w/ grating sensations

- aggravated by activity, relieved by rest

Arthritis of glenohumeral joint

- shoulder pain can result from this and thus should have their neck examined when presenting with shoulder pain

Degenerative cervical disk disease

- motor weakness to deltoid

- diminished biceps reflex

5th cervical root irritation

- weakness of the biceps

- brachioradialis reflex is diminished

- sensory disturbances in the thumb

6th cervical root

- triceps strength and reflex are diminished

- sensory disturbances in index and middle finger

7th cervical root

- "golfer's elbow"

- site of attachment for common flexor tendons

Medial epicondylitis

- "tennis elbow"

- usually appears in late 30's to 40's from overuse

- acute pain with extension of wrist and fingers (grasping)

- tenderness over dorsal aspect of forearm

- site of attachment for extensor tendons

Lateral epicondylitis

- direct blow or fall onto the elbow can damage this and cause bleeding into tit

- can cause inflammatory reaction that persits even after blood is reabsorbed

- no affect on elbow motion

Olecranon bursa

- extensor surface of the ulna should be visually inspected and palpated for the presence of these

- can accompany severe rheumatoid arthritis

Subcutaneous nodules

- in cubital tunnel on medial side of elbow, this can occur

- causes pain in elbow, numbness in ring and little fingers particularly at night

- gently tapping over cubital tunnel produces pain and tingling

- may be caused by repeated bending motions or resting the elbow on the car door while driving

Entrapment of the Ulnar nerve

- pain and tingling elicited by gently tapping over the cubital tunnel

Positive Tinel's sign (at elbow)

- palpate the ulnar styloid process, anatomic snuffbox, dorsal and volar surfaces of the wrist, transverse carpal ligaments, and synovial sheath or joint cavity

Wrist exam

- formed by the tendons of the abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus

- triangular depression over dorsolateral aspect of wrist

- tenderness at floor can indicate fracture of the scaphoid

- pain on palpation of the tendons may indicate tenosynovitis

Anatomic snuffbox

- caused by repetitive grasping, turning or wringing motions

- pts report pain and creaking with movement of the thumb

- may progress up forearm or down thumb

- assessed with Finkelstein test where pt bends wrist in ulnar direction with thumb stuck inside closed fist

de Quervain's tenosynovitis

- formed by arched carpal bones spanned by the transverse carpal ligaments

- median nerve lies within the tunnel

Carpal Tunnel

- most common nerve compression syndrome in the upper extremity

- tingling pain in the 1st 3 digits

- tested by pain numbness or tingling in at least 2 of 1st 3 digits w/o palm or back of wrist (Classic hand diagram)

- also positive test w/ palmar symptoms only on ulnar side (Probable hand pattern)

- Tinel's/Phalan's test also used (not specific)

Carpal Tunnel Syndrome

- trauma to the wrist, rheumatoid arthritis, collagen diseases, hypothyroidism, diabetes mellitus, amyloidosis, improper use of a keyboard

Causes of Carpal Tunnel Syndrome

- cystic structure that arises from a synovial sheath or joint cavity

- contains fluid similar in composition to joint fluid and is connected by 1-way valve to synovial cavity

- pts complain of painful lump aggravated by movement

- mostly benign, may compress nerves

Ganglion