IN GENERAL:

First, do no harm
When in the forest, look for trees, not zebras
Better is sometimes the enemy of good
If patient doesnt improve, 1. diagnosis is wrong 2. treatment is wrong
Observe patient posture, gate, and behavior
Does the injury match complaint, injury vs. organic pain
Previous evaluations? when? who? outcome?

General questions, then specific

Is there anything else you can tell me? any other symptoms?
LOPPPPPQRST
Family History: parents, siblings, children (sex, ages, health)
Social history: married, alcohol, smoke, activity, work
Medications and other physicians
ROS:
Head/neck: headache, dizzines, visual, hearing, ringing, balance, sinus, dental,
sick, facial numbness
Chest and heart: chest pain, hypertension, shortness of breath
GI: heartburn (GERD), ulcers, colitis, bowels, pain with meals
Genito-urinary: kidney stones, blood in urine/stool, UTI, hernia, STDs
Endocrine: Thyroid, menstrual cycle, serum glucose
Musculo-skeletal: spine, extremities

Remember: when no mechanism of injury or cases dont make sense, stay on high alert
and look further...
Tests:
a. Provocative: Nerve traction
b. Mechanical
c. Reflexes
d. Sensory
e. Motor

FULL SPINE:
CERVICAL:
Key Questions:
Pain with coughing, sneezing, straining?
Numbness or tingling anywhere?
Dropping things?

Weakness anywhere?
Loss of speed or dexterity on keyboard?
Symptoms occurred previously?
Any physicians previously? who? What was done? Did it help?
Scapular:
Pain between (C7), under (C6), or on top of shoulder blades?

Red Flags:
Trauma: MVA speed, direction, seat belts, airbags
LOC: Epidural or subdural hemorrhage also
Bladder disfunction:
Increased frequency = cervical cord compression, myelopathy
Urinary Retension = Cauda Equina Syndrome
Tests:
Physical exam
AROM
Reflexes: ALWAYS DO ALL REFLEXES, clonus (1, 2, or 3 beat or flutter) and
Hoffmans; monitor 2-3x a month and refer to neurologist is necessary
Sensory dermatomes
Moto myotomes
Provocative tests
EMG:
useful often, unless minor deficit; note specific diagnosis
Wait 4+ weeks to order to avoid false negative
Reveals axonal damage; polyphasicity = irritated nerve
Devervation = nerve getting worse = SERIOUS
Reinnervation = nerve getting better
Recovery takes 1mm/day. long time denervation may not recover
Drcampion.com for common tests in L.A. area
MRI:
Usually without contrast
Gadolinium for non-responsive post op
CT: Myelogram is gold standard but not ordered as often
Others: Myelogram, CT myelogram, facet block, nerve block, epidural, discogram
Myelopathy:
Difficulty picking up keys, coins off table? Buttons?
Loss of balance? Falling?
Change in temp in legs? look for cold sensation, cold or icy water; uni or bilateral
Electric down spine or LE? Look for during C/S ROM
Urinary/bladder problems?
Disc problems combined with central stenosis
DO NOT PERFORM VALSALVAS!! Not worth it.
Disc/facets:

 Not many disc protrusions after 40 years;

Desiccation with age and overuse
Reduced disc height -> Facet arthropathy and foraminal stenosis
Facet Joints:
C2-3 to head and neck; C5-6 to neck and shoulders
Facet arthropathy = local pain
Instability:
Commonly missed; seen by many orthos, chiros and PTs
Chronic pain, weakness, cracking, sliding, neck doesnt support head
Flexion/extension x-ray, fluroscopathy, (make sure muscles arent guarding)
Torticollis:
Acquired is rare
Many often antalgic positions from C/S pathology
Stingers/burners:
Common in sports and stretch injuries
Resolve in 15 min to few weeks
Repeat stingers risk central stenosis
Fracture:
Do not perform tests that stress fx (flex/ext. x-rays)
Order or take x-rays for Stat reading
C5:

Cervical pain, shoulder paresthesia/pain

C5 dermatome
biceps and brachioradialis reflex
deltoid, biceps brachii, serratus anterior strength
provocative: cervical compression, valsalva, shoulder depression
Relief: distraction, bakodys

Cervical pain, radial forearm/hand paresthesia/pain, retroscapular pain, winging

C6 dermatome
biceps and brachioradialis reflex
biceps brachii, serratus anterior, brachioradialis, wrist extensors and grip strength
provocative: cervical compression, valsalva, shoulder depression
Relief: distraction, bakodys

C6:

C7:
Cervical pain, dorsal forearm/hand paresthesia/pain, winging
C7 dermatome
tricep reflex

 finger extensor, tricep brachii, serratus anterior or grip strength

provocative: cervical compression, valsalva, shoulder depression
Relief: distraction, bakodys
C8:

Cervical pain, ulnar forearm/hand paresthesia/pain

C8 dermatome
finger flexors, wrist flexors or grip strength
provocative: cervical compression, valsalva, shoulder depression
Relief: distraction, bakodys

Lower cervical pain, upper thoracic paresthesia/pain,

T1 dermatome
interossei strength (ulnar neuropathy)
provocative: cervical compression, valsalva, shoulder depression
Relief: distraction, bakodys

T1:

Sprain Strain:
Pain with ROM
No valsalva, sensory loss, or motor loss
Normal reflexes
Acute Disc w/ radiclopathy:
Maybe pain with ROM
Valsalvas, sensory and motor deficits
Diminished reflex at appropriate level
THORACIC:
Key History Questions:
Corticosteroid hx
Hx of CA
Known hx of autoimmune disorders
Hx of herpes zoster
Hx of recent surgery
Hx of recent thrombus
Difficulty with urination
Urinary frequency
Observation:
Winging, scoliosis, SOL, buffalo hump (cushings or chronic corticosteroid), skin
lesions (Herpes Zoster, moles, leasions)
Tests:
4

 All reflexes, AROM, valsalva, rib compression, SP percussion, palpation

Sprin/Strain:
Lifting or acute trauma
Palpable, tender myospasms
No valsalva, no rib tenderness, normal reflexes
Thoracic Disc Protrusion:
Mimics rib pathology: follows intercostal space/nerve
(+) valsalvas,
Pain lasts longer than normal
Confirm with MRI (protrusion, foraminal or central stenosis, cord
compression/signal change
EMG (posterior rami involvement
Cord Compression:
Patellar and achilles reflexes, clonus
No Hoffmans reflexes
Change in gate, Urinary frequency
DJD:
Spine stiffness with gradual onset (same in C/S and L/S); Subtle kyphosis
Age appropriate
Schuermanns Disease:
Young, 13-17, increased kyphosis
Endplate irregularities
Irregular vertebral plates, disc narrowing, 5* wedging, schmorls nodes (3 or more
vertebrae)
Exercise to keep spine mobil, no braces, maybe surgical stabilization
Compression Fractures:
common; older females, minor trauma
pathologic from CA or tumor
X-ray 1st diagnosis tool, MRI for bone edema
If young: trauma, nutrition (anorexia), overtraining (endocrine)
Posture Syndrome:
Upper/mid T/S pain
Poor ergonomics
Scapular protraction, functional kyphosis
Tight protractors & paraspinals; weak retractors
Posture brace
Ankylosing Spondylitis:
Male, tall & thin

 T/S and L/S stiffness, SI pain

X-rays, HLA B27, sed rate
Herpes Zonster:
Unilateral break out; Thorax, painful
Refer; If acute, stay clear of office
Pulmonary Emboli:
Presents as T/S paraspinal spasms, knots, aching, progressive
Hx major surgery, long plane flights, prolonged bed rest, LE trauma, heavy steroids
Medical Emergency; 911
Thoracic Epidural Arteriovenous Malformation (TEAM):
Associated with vascularized intramedullary lipoma
Wraps around spinal cord and shunts blood away
Lipoma may compress cord w/ vascular bed
Melopathic symptoms, balance problems (stairs), falls, sprain/fx ankles
Interscapular pressure intolerable
Females 20-45 (estrogen or birth control?)
Maybe associated w/ surfers myelopathy, spinal MS
Patellar & achilles hyperreflexia, LE clonus, off balance, No hoffmans
MR, then with gadolinium through heart vessels
LUMBAR SPINE:
Possible Causes:
Disc, Spinal nerve root, ligaments, muscle, tendons, fascia
Facet arthropathy, facet meniscoids, pars fracture, spondy, bone marrow edema
subluxations, SI arthropathy, metastatic lesion, fractures
Arthritis, AS, kidney stones, abdominal aortic aneurysms
History:
Valsalva, numb, tingling, tripping, stumbling, increased walking up hill/ramp,
clicking and popping, translation
Worse in morning: arthritis/ autoimmune disease (Sleeping in prone makes hip
flexors cause dull LBP)
Worse in PM: mechanical, disc, facets
Bladder or urinary problems (cauda equina)
Red Flags:
Urinary retention, saddle paresthesia
unrelenting pain in any position
Recent infection, current fever
Trauma, radicular pain
Cancer: Patient 50, Previous history, unexplained weight loss, no respond to
conservative care for one month, night pain/sweats

Tests:
All Reflexes, AROM, Valsalvas, bechterews, SLR, Bragards, WLR
Yeomans, Nachlas, Elys, Kemps, SIJ Motion, L/S Motion
Myotomes: anterior tibialis, perronei, EHL, gstroc, hamstrings, glute max
Dermatomes, leg length
Disc:
Internal disruption and annual fiber tears
Pain with coughing, sneezing, straining?
Radicular pain
Spondylolisthesis:
90% at L5, peaks at 5-10 years, adolescence
X-ray in flex and exend, weighted
MR (disc, nerve root, edema); CT and SPECT scan (hot and cold areas)
SI joint:
prolonged bending, standing from bent, lifting
Sharp initially, radiating, point to SI
No Valsalva, motor or sensory, normal reflexes
Muscle tender at proximal (glute max, iliopsoas)
Palpate, leg length, SI tests for pain
SIJ Instability:
Trauma w/ severe pain, point to lower L/S
Fail to improve with conservative care
Reports slipping in SI
Marked hypermobile unilaterally, subluxation again right after adjustment
Visualize movement at public symphysis
Treat with Prolotherapy best; epidurals, nerve block, facet block
Piriformis Syndrome:
Buttock and post. thigh pain
Runners, bikers, tennis players
SLR maybe normal, reflexes & motor normal
Piriformis very tender
EMG maybe positive
Foraminal Stenosis:
Radicular pain, LBP, Dermatome paresthesia
No valsalvas
X-ray show osteophytes, DDD, intraforaminal protrusion
MRI, EMG with motor deficit
Central Stenosis:

>50 years, bilateral often

Multiple Dermatomes
Improved with spine flexion (open central foramen, IVFs)
MRI, CT, flex/extend

Vascular claudication:
LE symptoms w/ activity, walking w/in certain time (consistent)
Flexion does not improve
Rest improves
Pars Fraxture:
Spondylolysis; Acute onset
Moderate - marked LBP in younger patient
Hitory of sports with load
Bone marrow edema on MRI
Sequestered Disc:
LBP and leg pain initially
LBP suddenly stops, Leg pain worsens
Perceived as improvement, but need imaging
Metestatic:
Early metastatic prostatic carcinoma
History or PE of cancer
MR to assess compression of cord
LOWER EXTREMITY:
Hip:
Iliofemoral DJD:
Very common; Pain or not
Trochanteric Bursits very painful, not serious
Gradual loss ROM (esp. rotation)
Assoc. Knee complaints usual (tibfem)
C/O groin/adductor referred pain
Xrays of hip and knee; pediatric knee = always look at hip
Any knee pain, look at hip
Labral Tears:

Present with hip pain

Usually painful clicking an popping
Full ROM but painful
Repair very successful, arthroscopic removes loose bodies
Long rehab

Femoroacetabular Impingement (FAI)

Femoral neck impinged into Glenoid fossa, rim and labrum
Often higher alpha angle (between femor neck and neck and head
intersection)
CAM impingement ??
Possible boney prominence on neck
o Articular cartilage damaged first -> loose bodies
Pincer Impingement:
o No boney prominence
o Acetabular labrum damaged first -> tear first
Just pincer = 5%, Just CAM = 16%, Both = 77%
Usually pain with 1. anterior groin 2. lateral trochanter 3. deep buttock
Physical exam:
o FEBERS
o Anterior impingement: Flexion with IR (+)
o Posterior Impingement: Ext with ER (+)
o Philippons circumduction test: Hip flextion, abduction, ext rot.
(pain) (measure distance from table to knee in ext rot and flex)
Avascular Necrosis:
Legg-Calve-Perthes (avascular to femoral head)
Male 4-5x more, 4-9 years old
C/O mild hip pain w/ limp
Insidious onset
10% bilateral, 17% trauma, 15% knee pain only
also subcapital fxs, posterior hip dislocation, corticosteroid use,
alcoholism, hyperlipidemia, pancreatitis, hemoglobinopathies
Slipped Capital Epiphysis:
8-17 years
rapidly growing or overweight
50% have had some trauma
chronic slippage, gradual pain and antalgia
children maybe knee pain only
Tochanteric Bursitis: (sub)
Trauma or unaccustomed overuse
Mild or severe pain
C/O hip pain but (Can or cant?) point to it
Pelvic Rock test (over Trochanter)
Therapy: conservative care, US, Cryotherapy, EMS, STM
Rule out Fx or avascular necrosis
Adductor Strains:
Myofascial junction of adductor magnus MC

Sudden pain, acute, tearing sensation

Overstretched, overuse, fatigue, poor conditioning, too much force
Hockey and soccer
Belly resolves fastest, origin slowest
Pain with passive abduction, active adduction (resistance)
DDX with lost ROM (DJD) and passive flexion pain (osteophytes/loose
bodies)
Use various ROM and resistive tests (drag foot)

Rectus Abdominus Tears:

sports Hernia not really a hernia
Adductor and lower ab pain
superior to inguinal area
Circular pattern of better and worse w/ activity
Causes
o 1. eccentric load in sports (stood up in play)
o 2. overuse in drills/sprints
o 3. CAM FAI leads to undue stress
Sit up, resisted and rotation
Brace against anterior iliac crest, place thumbs over inferior rectus
abdominus while pt is relaxed and mildly press deep into abdomen.
Instruct pt to perform a sit-up. The doctors thumbs should displace
superficially equally and simultaneously.
Usually major athlete and needs surgery
Osteitis Pubis:
Pain at rectus origin on pubis (warn of palpation)
Adema on MRI or abnormal uptake on bone scan
Hamsting Strains:
Athletic endeavor, overstretch
Localized pain w/palpation, edema
Grade II with palpable gap and bruising
NSAID use can increase bleeding
Lateral or Medial
DDX S1 radiculopathy (other motor weakness, decreased dermatome)
SLR (+)
Causes: Tight Hams, Ham/Quad imbalance (unilateral or Bi), poor warmup, too much stretch, no speed training
Rectus Femoris Strains:
Common for athletes at high speeds
Caused: overtraining, poor warm up, muscle imbalance
Often at midbelly
Some AIIS pain (adolescents)
Check avulsion

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IT Band Syndrome:
DDX from L5 Radiculopathy
No LBP
No reduced Dermatome or myotome
Nobles Compression Test

Knee
*** Note: Lumbar radiculopathy can predispose lower extremity joints to injury,
resulting in multiple diagnosis. ***
General Questions:
Does the knee give way? (ACL or Meniscus)
Does the knee Lock? (Meniscus or loose body)
o What do you do? How often? When did it began?
Pain walking up or down stairs, mainly down? (patellofemoral pain)
Acute knee effusion? (ACL or Osteochondral lesion, bleeding/hemarthrosis)
o Quad weakening reflex, must fix effusion first
Valgus Injury? (MCL and Medial Meniscus)
Verus Injury? (LCL, rare)
Rotary Injury? (meniscus and ACL)
Hyperextension? ACL
Hyperflextion? PCL
Posterior Shear (Tibia meets dashboard)? PCL
Combine 1. mechanism of injury 2. symptoms 3. location of pain
Always compare bilaterally for general laxity
Meniscus:

Joint pain, clicking, giving way and maybe locking

Maybe previous resolved pain, but now intolerable
Repair is longer rehab, but spares material
Cutting or rotary injuries; Distance running
McMurrays, joint tenderness, Anterior Drawer, mild effusion
MRI to confirm

Partial or complete tear; overstretch

Vascular supply could cause marked effusion
Rotary force, blow to knee, or hyperextension (pop)
Accompanied by Medial Meniscus
Assess ASAP before swelling
#1 Lauchmans; #2 Anterior Drawer (Posterior sag false negative)
MRI, Xray, LARS synthetic ligament, brace

ACL:

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PCL:

Hyperextension/ Posterior shearing (rare)

Posterior sag sign
MRI without contrast, X-ray
DDX Pes Anserines

Valgus injury, slip and fall

Medial knee pain weight bearing, turning in bed
Grade II and III sleep with brace
Valgus stress test, tenderness
Look for Med. Meniscus, ACL and excessive pronation
MRI w/o contrast, X-rays; only surgery w/ multiple injuries

Varus force, rare, Supported laterally w/ ITB, popliteus, glut max

Varus Stress test, tenderness, history

MCL:

LCL:

Bakers Cyst:

End of knee effusion, herniation of post. Capsule

Pursue other pathology; always a result of derangement
Pressure behind the knee; full feeling
One popliteus fossa tighter and full than other
Check popliteus muscle (medial rotator and stabilizer); fibrous, swollen
Check Popliteal pulse and aneurysms

Osteochondral Fractures:
Sharp pain and immediate effusion
Limp and need crutches
MRI and X-ray immediately, May need drained
Fragments can be left and erode knee
EMS unit (HVG or interferential), Ice pack, CPM if fragment removed
Osteochondral Dessicans:
Trauma, Ischemia, aberrant ossification, Hereditary abnormality
Medial femoral condyle (tender)
Adolescence, may be bilateral
Wilsons Test Medial rotate Tibfemoral joint and extend; Pain at 30*
and alleviated when laterally rotated; MRI and X-ray
Bone Marrow Edema/ Bone Contusion:
Stress on bone (axial load, transverse stress, direct compression)
Could lead to fracture (occult fracture)
Chronic Effusion:
Meniscal tears, loose bodies, ACL and MCL, Decr. Hamstring/quad
strength (inhibited by effusion)

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Boggy or spongy superior to patella and joint line

Warm, but no redness; Popliteal fullness
HVG very effective to reduce
Check Seronegative arthritis, RA, Septic joint (lab tests

Patellofemoral Pain Syndrome: (PFPS)

Many causes include:
Abnormal Patella Tracking (medial and lateral)
Chondromalacia
Patellofemoral DJD
Patellar tilting
Patellar Tendinitis and Quadricep Tendinitis
Jumpers Knee
Overuse, direct impact of Patellofemoral joint, excessive pronation
Increased Q-angle theory?
Abnormal Patellar Tracking:
Can track either medially or laterally (dont lateral release)
Pain under kneecap, walking downhill or stairs
Atrophied Quads, strengthening = more pain
Taping can help; On-Track Brace
Tape and have patient exercise
Abnormal Patellar Tilting:
Lateral MC
Increased stress on lateral facet
May not be visible; Sunrise view, MRI, taping
Chondromalacia:
Cartilage Softening
Describes more than one pathology
Pain and crepitus, below knee cap with flex/extension
Young population
Blistering-like effect on cartilage
DDX from PF DJD (loss cartilage, pain from bone)
Patellar Tendinitis:
From overuse (sports/work)
Walking downstairs, deceleration, squatting
Worse in morning, better when moving
Tender palpation, some edema
Jumpers Knee:
Must be at poles (inferior or superior)
Micro tears and necrotic tendon tissue
4 grades, II and III will not improve, IV complete rupture

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3

Surgically debrided and tendon sutured to patella (9 months)

Redundant synovial fold, medial knee MC

Femoral condyle erosion
Clicking and popping
MRI

Plica:

Primary Tumors:
Osteosarcoma MC of knee (2nd most primary bone)
o 60% knee, 40% distal femur, Males 2:1 10-25 years
Chondrosarcoma 3rd most primary bone
o 7% in knee, 40-60 years, Male 2:1
Neoplasm:

Metastatic carcinoma: from lungs to knee 1.5%

Look to thyroid, breast, prostate, melanoma
BONE SCAN

Proximal Tibiofibular Hypomobility:

Lateral knee pain (proximal tib-fib joint)
Responds great to manipulation
Osgood-Schlatters Disease:
Tib Tuberosity apophysitis
Peak height velocity in youth
Pain and swelling over tib-tube (jumping/running)
Reduce activity, resolve after growth
MRI and X-ray may be helpful
Pes Anserine Tenderness and Bursitis:
Semitendinosis, Gracilis and Sartorius
Marked tenderness and adema
Runners
DDX MCl and check hamstrings
Septic Joint:
Recent Surgery
Effusion, pain, temperature/hot, redness, erythema
Drain immediately before bacteria eats all cartilage (within 72 hours)
Cellulitis:
MC LE, must have portal of entry
Patch of erythema, draw line around
Must have antibiotics
FOOT AND ANKLE

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Sprains:
xxxxxxxxx
Posterior Tibialis Tendon:
xxxxxxxxx
Achillis Tendon:
xxxxxxxxx
Tennis Leg:
xxxxxxxxx
Deep Vein Thrombosis (DVT):
xxxxxxxxx
Tarsal Tunnel Syndrome:
xxxxxxxxx
Plantar Fasciitis:
xxxxxxxxx
Mortons Neuroma:
xxxxxxxxx

Stress Fracture:
xxxxxxxxx
Shin Splints:
xxxxxxxxx
Hallux Valgus:
xxxxxxxxx
Turf Toe:
xxxxxxxxx
Sand Toe:
xxxxxxxxx
Gout:
xxxxxxxxx
Fat Pad Syndrome:
xxxxxxxxx
Vascular Intermittent Claudication:

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 xxxxxxxxx
Overlapping:
xxxxxxxxx

UPPER EXTREMITY:
SHOULDER
Night Pain?
Clicking and popping, grinding, clunking? Painful? Labrum tear (dominant hand)
U/E paresthesia?
Ever dislocated or subluxated?
Overhead athlete?
What activities aggravate?
Old treatment? Did it work?
Point with one finger.
ANATOMY:
Acromioclavicular DJD common by 40 years
Subacromial Space: Subacromial bursa, supraspinatus tendon, lg head of bicep tendon
Acromion: I. Flat II. Downsloping III. Hooked IV. Concave
Coracoacromial Lig: Coracoid to Acromion; in subacromial space; release = instability
Glenohumeral Lig: 1st line of defense again instability (static)
Superior: prevents inferior displacement of humerus; inferior drawer test
Corracohumeral: prevent inferior displacement
Middle: prevent Anterior translation (anterior drawer/fulcrum test); medial to lesser
tuberosity and adhere to subscapularis tendon.
Inferior: prevent anterior translation; hammock/sling; taught at lateral rotation;
Origin: glenoid fossa, neck and labrum; Insert: anatomical neck of humerus
Posterior: Prevent posterior translation; rare
Labrum: pain and instability; biceps tendon
Deltoid: Main mover of the GH joint.
Rotator Cuff: 2nd line of defense of
Subscap: medial rotation; depress humerus; upper and lower subscap nerves
Intraspinatus: Lateral rotation; subscap nerve
Supraspinatus: abduction; suprascapular nerve
Teres Minor: Lateral Rotation
Subacromial Impingement Syndrome:
Rotator cuff tendons (supraspinatus), bicep tendon, subacromial bursa
Medial rotation and any elevation; full flexion
Posterior capsule tightness; weak serratus anterior; supraspinatus atrophy

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 Primary = without GH instability

Secondary = with GH instability
Inflamation, edema, crepitus, weak abduction and lateral rotation, limited ROM,
AC joint tenderness
Acromion morphology, Subacromial spurs, AC joint DJD, calcific tendonitis,
enlarged coracoid process, posterior capsule tightness
Night pain when sleeping ON shoulder
Night pain regardless = Rotator Cuff tear
Neers Test; Hawkins Kennedy; Clancys Test (abduct 90 w. internal rotation, then
horizontal abduct.); Feders test (Full internal rotation and flexion); Ellmans test
(sidelying, compress humerus and have patient rotate back and forth for clicking)
Rotator Cuff Tear:
Supraspinatus MC (chronic impingement)
Night pain regardless of position
Pain and weakness in abduction
Referred pain NOT passed elbow
DDX C6 radiculopathy (infra, supra, serratus)
Tests: Jobes (empty can), Standing 30* abduction, Sidelying 45* abduction,
Blackburns, External rotation lag sign (ERLS), drop test, Lift off, Internal and
external at 90/90 and 0/90
Glenohumeral Instability:
Supported by Sup. Glenohumeral Ligament and Coracohumeral lig.
Rotator cuff and biceps statically support
MC anteroinferior (medial or inferior GHL)
Pain posterior or global
Look for labrum tear
History:
Throwing or push up/bench press
dislocation/subluxation, trauma, slip in and out
Overhead athlete
Painful popping or clicking, aresthesia (4th-5th digits)
Posterior instability from FOOSH
Pseudolaxity:
GIRD and SLAP (overhead), SICK scap (overhead/non-athletes)
Pain in late cocking stage
Deceleration could be slap (type II can also break labrum ring)
Trauma
Chronic external rotation
GIRD: Glenohumeral Internal Rotation Deficit
Loss of internal rotation
posterior capsule tightness
Loss of internal rotation > gain of external rotation

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 Could tear labrum or undersurface of rotator cuff

SLAP: Superior Labrum Anterior Posterior
overhead athletes in late cocking phase
ECCENTRIC bicep overload on follow through
biceps tendon vertical and twisted at posterior superior labrum; pulls off
Posterior shoulder tightness
GIRD is present
Sudden onset of biomechanical injury
Compress humerus from fall
Popping, clicking, grinding, clunking, pain
History of impingement or instability surgery
ask previous treatments and outcomes; sport, level, duration
Tests: palpate tenderness, OBriens, Speeds, Yergasons, apprehension, relocation
Type I: Fraying and degeneration, still attached
Type II: Bicep anchor/labrum detached from glenoid
Type III: Bucket handle tear; the rest attached
Type IV: Bucket handle tear; extend into bicep and displaced to joint
MR with contrast
SICK Scap: Scapular malposition, Inferior medial border prominence, Coracoid pain and
malposition, Dyskinesis of scapular movement
Pain
Anterior (coracoid) and superior (AC) shoulder
posteriosuperior scap
proximal lateral arm (subacromial)
Proximal radiatig pain (C-spine, paraspinals)
Asymetrical lower malposition in throwing arm
Type I:
Inferior medial scap border prominent; Superior less
Coroacoid tenderness
SLAP
Type II:
Medial Scap border prominent, SLAP
Inferior appearance 2nd to protraction/tilting
Lateral and abducted scap
Type
III: Superomedial border prominent

Lack of full flexion

Tests: Scap assistance; Protract scap and look for impingement and pain; Manually
set scap reduces pain; TOS tests;
Suprascapular Neuropathy:
weak infraspinatus and supraspinatus
Deep ache, insidious onset, progressive weakness
overhead athletes
MRI with contrast, EMG for 2 muscles; all other normal

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 Tumor, labrum tear, compress spinoglenoid notch

r/o cervical radiculopathy
No cervical history
Winging Scapula:
Long Thoracic or dorsal scap neuropathy
C5, C6 or C7 radiculopathy
Subscap tendon rupture, SICK scap
Tests:
observe scap at rest and during adduction from above
Serratus muscle test; Punch test, C/S exam
Wall push up (high=C5,6; Low=C7)
Brachial Plexopathy:
paresthesia, pain, weakness; Whole hand feels funny; Lower trunk distribution
Anterioinferior GH instability
History:
Cervical trauma? Stinger? dislocation/subluxation of GH? Shoulder trauma?
Cold flu or infection? Chest pain or chronic cough?
If Cervical, shoulder, and TOS normal, check viral, bacterial or pancoast tumor
Cofields, Fulcrum, drawer, apprehension
EMG r/o radiculopathies
NCV r/o ulnar or median neuropathies or double crush
TOS
Diagnosis of exclusion- cancel everything else out!
r/o cervical radiculopathy, ulnar or median neuropathy, brachial plexopathy, Double
crush syndrome, combo
Arm asleep, numb/tingling fingers, armpit pain
Tests:
ROOS/Lefferts, Adsons, wrights hyperabduction, Edens costoclavicular,
Supraclavicular compression,
EMG, NCV
Calcific Tendinitis:
Wringing tendon in adduction
Treat with Heavy B12
Biceps Tendon Tears:
Pain should be there at first, but go away quickly
Proximal tears due to chronic impingement
Over 50 years
lose 15% overhead power
Distal tears from trauma
Sudden load on biceps, younger

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ELBOW
Extensor Tendinosus:
Lateral epicondylitis, tennis elbow
Repetitive, eccentric load; forehand and serve
Extensor carpi radialis brevis -> extensor digitorum -> carpi rad. longus
TTP over lateral epicondyle, ECR and ECU, supinator
Wrist extensor weakness
Resisted 3rd digit extension = Extensor Digitorum
Mills Test
Radial Tunnel Syndrome:
Rare; radial nerve between supinator heads in anteriolateral elbow
Anterior radial head, medial edge of ECRB, edge of pronator
Posterior Interosseous Syndrome:
Motor deficit only of radial nerve
weak wrist extension, 1st and 2nd digit extension
Flexor Tendinosus:
Medial epicondylitis, golfers elbow, eccentric repetitive load
TTP at medial epicondyle, wrist flexor and pronator teres
weak and painful wrist flexors
Reverse Mills Test
Tricep Pathology:
Very rare; trauma or steroid use
Pain, tenderness and weakness
Little League Elbow:
Adolescent patient with medial elbow pain and tenderness
Repetitive valgus load (pitching, curve ball)
Medial anterior oblique ligament and medial epicondyle epiphysis fragmentation
Osteochondritis dissecans of capitellum
Valgus stress laxity
Crepitus at radial head with supination and pronation
Biceps Tendon:
Distal are rare and younger trauma
Tendinitis uncommon from repetitive strain and load
Biceps muscle:
Rare, but in eccentric load causes fatigue and tear
Type I or II tear
Increased carrying angle
Edema, tightness and tenderness over muscle belly

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Ulnar Neuropathy:
Very common; overstretched or compressed
Numbing, tingling and pain in Ulnar distribution of elbow/wrist
Osteophytes, fibrous bands, ganglions in cubital fossa
Exacerbated in elbow flexion
May have just wrist pain
C8 distribution should have other C8 problems
Tinnels sign possible, Abduct fingers against resistance (interossei muscles)
Maybe sensory only, motor only or both
Nerve conduction velocity study is COMMON
Ulnar collateral ligament laxity:
Throwing sports
Medial elbow pain or laxity with valgus or axial load
Tenderness at UCL
Look for Tinnels sign and Ulnar neuropathy
DJD:
Not Common
aching, Deep pain, loss AROM and PROM, catching, clicking
Trauma or overuse
Olecranon Bursitis:
Olecranon impact, fall, small cut
If hot, red or swollen, DDX septic bursitis
Pronator Syndrome:
Median neuropathy at pronator teres (or carpal tunnel)
Forearm pain
Pronator teres tender or hypertrophied
3rd digit flexion pain or weakness
Order NCV
Brachioradialis Strain:
common, carrying heavy loads when not used to it (luggage)
Muscle weakness with pain, tender midbelly
resolves slowly
WRIST
History questions:
Trauma or not, pain, stiffness, looseness, instability/laxity, crepitus, combo?
FOOSH: scaphoid fracture, carpal instability, distal forearm fx, epiphyseal damage

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Proximal Row: Scaphoid, lunate, triquetrum, pisiform

Distal Row: trapezium, trapezoid, capitate, hamate
Ligaments: Scapholunate, Lunotriquetral, Capitolunate
Radius absorbs 80%; Ulna 20%
Ulna Variance: positive = longer Ulna, Negative = short Ulna
Triangular fibrocartilage complex:
Meniscus, Ulnar collateral lig., dorsal & volar radiolunar lig. extensor carpi ulnaris
unstable ulnar wrist and radioulnar joint
Ulnar positive common
repetitive weight bearing or single trauma
distal ulnar pain, w/ supination
Radial deviation w/ axial loading and shearing = pain
DDX ulnar neuropathy
Xray and MRI
Scapholunate Dissociation:
radial or dorsal wrist pain after FOOSH
capitate between scaphoid and lunate, tearing scapholunate and radioscaphoid lig.
Watsons test
x-ray and MRI
Lunotriquetral Dissociation:
pain on dorsal ulnar wrist
fall on flexed or hyperpronated wrist
lunotriquetral ligaments torn or stretched
Bollattement test for painful clicking or popping
X-rays and MRI
De Quervains Tenosynovitis:
Radial wrist pain along tendons (prox to styloid)
Hx of forceful gripping, ulnar deviation, thumb use
abductor pollicis longus and extensor pollicis brevis
Finkelsteins Test
Median Neuropathy:
Very common at carpal tunnel
pain, numb, tingling at volar hand (1st, 2nd and radial 3rd)
clumsiness, weak grip, thenar atrophy
direct trauma or prolonged flex/extension
ganglion cyst, tendon hypertrophy, fx, dislocation, fluid, pregnancy, RA, diabetes,
vit B deficiency, connective tissue disorders
Carpal tunnel syndrome (grocers, typers)

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 Phalens, Reverse phalens, tinels, NCV of median nerve

Pronator Syndrome (capenters, weight trainers)
volar forearm, pronator teres hypertrophy and tenderness
3rd digit flexion weakness
Ulnar Neuropathy:
Tunnel of Guyon: between pisiforma and hamate
Numb, tingling, pain in 4th and 5th digits
constant compression (cyclist/handlebar palsy)
tinels sign or abduction motor decreased
Scaphoid Fracture:
Pain in snuff box, FOOSH
pain 3-6 months after injury
look for AVN
X-rays often miss so take MRI
Hook of Hamate Fracture:
pain distal or radial to pisiform
fall or hit on hyperthenar eminence
Keinbocks Disease:
Stiff and painful wrist from trauma
AVN of lunate from stress or compression fx
CT and MR
HAND
1. Rehab for work comp major injuries
2. Various arthritis
3. Tendinitis, tendinosus, stenosing tenosynovitis, lig. laxity, peripheral neuropathies or
radicular pain
Rheumatoid Arthritis:
Female, 20-40 yo, autoimmune
finger and wrist pain, begin MCP and PIP joints (wrists, knees, ankles, toes)
Warm, swollen & tender joints
Pannus causes swelling and erosion
Flexor contracture and ulnar deviation later
Labs: RF factor, ESR, C reative protein, CBC (hypochromic, normaocytic anemia)
Psoriatic Arthritis:
Unilateral finger pain, non traumatic, sausage finger
SI pain
Hx of psoriasis or skin leasions 80% (arms, legs, scalp)

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 RF (-), ESR and Uric acid elevated, HLA B-27,17

Radiology key
Gamekeepers Thumb:
Pain at base of thumb (fall, ski poles, ball)
tender and swelling at web
Hyperextension, hyperabduction = ulnar collateral lig. tear
Tear = no pinching strength
Stress x-ray
Bennetts Fracture:
acute and severe pain after axial compression of thumb
Deformity and rapid swelling
Fragment held by ligaments with dislocation moving over it
Trigger Finger:
Thumb getting stuck when flex/extend
overuse or grasping
Stenosing tenosynovitis forms
Distinct nodule at base of phalanx is tender and snaps

ADDITIONAL CONDITIONS:
CHIARI MALFORMATION
Definition:
Hindbrain maldevelopment resulting in herniation below foramen magnum
#1 cause of syringomyelia w/ osseous abnormalities
Types I (Adult type), II and III
Small foramen magnum
Tonsilar herniation at least 5mm
DDX from migraine, fibromyalgia and MS
Epidemiology:
Females, 20s -30s, rare
25% previous trauma
Whiplash and direct blows to head
Syrinx formation drives CSF into interstitial spaces of the cord.
Some resolve spontaneously - CHIN TUCK movement
Decrompress tonsils or widen Foramen magnum
Symptoms:
Suboccipital HA: heavy, crushing pressure, pounding when severe

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 Ocular disturbances: floaters, flashing, blurred, photophobia, diplopia

Otoneurological: dizziness, disequilibrium, pressure, tinnitus, decr. hearing,
hyperacusis, vertigo, oscillopsia (objects swing)
Symptoms increased by exertion, valsalvas, mensus, or posture change
DDX Multiple sclerosis
Dysphagia, sleep apnea, dysarthria, tremors, palpitations, poor coordination
Spinal cord dysfunction: muscle weakness, paresthesia, hyperesthesia, nonradicular pain analgesia, anesthesia, spasticity, burning, poor positioning
chronic fatigue, impaired memory, cervicogenic pain, LBP, nausea/vomiting
HEADACHES:
Warning:
Worse headache Ive ever had
Sudden, severe HA, vomiting, neurologic signs, malignant hypertension
After trauma
Aneurysm, hemorrhage, tumor, infection
Questions:
Flu or cold, recent given or stopped prescription, reading/glasses?
Stopped using caffeine? Caffeine help?
Smoking, alcohol, recreational drugs, toxic chemicals?
Recent diagnosis? Medications? Did they help?
Flashing lights, zigzag lines, blind spots, odd vision?
Cluster Headache (rare):
middle aged males
Severe, unilateral, orbital, supraorbital or temporal
Peaks in 10-15 min; lasts 15 min - 3 hours
At night, cycles over weeks/months; 1-8/yr
Associations: conjunctive infection, runny nose, congestion, ptosis, sweating, eyelid
edema, extreme agitation
History of smoking or alcohol abuse
P activation and impairment
5 episodes to qualify
Indomethacin treatment; no NSAIDS
Cervicogenic Headache (18%):
Daily headache, loss C/S AROM
Myofascial, deep muscle/ligaments, nerve root/dorsal ganglion, IVD/cord
compression
No neurologic deficit
Migraine Headache (18%):
Female
Unilateral, throbbing, preceded by aura (15%)

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blind spots, flashing lights, zigzags, funny vision

Hours to days
Photophobia, nausea, vomiting
Familial hx, neurogenic component w/ vascular
Sleeping and eating habits, pollutants, meds
chocolate, caffeine, nitrates, cheese, nuts, wine
Classic: with aura (15%)
Common: without aura (85%)

Tension Headache (MC=38%):

Frequent occurrence, lasts for days/weeks, worse afternoon/evening
Bilateral, suboccipital, supraorbital
Less muscle tension, may be transformed migraine
Trigger points, tight muscles
Responds well to NSAIDS
CONCUSSIONS
Hitstory:
Direct trauma, accel/deceleration, or rotary injury
Retrograde amnesia, confusion, no awareness of surrounding, disorientation
Emotionality, feeling in a fog, irritability, drowsiness, loss of focus,
Early signs: Cognitive deficits, word searching, vacant stare, slurred speech,
ringing of ears, fatigue, headache, nausea, vomiting
May loose consciousness, dizziness, vertigo, photophobia
Late symptoms: persistent headache, light headedness, poor
attention/concentration, memory dysfunction, easily fatigued, Irritable, low
frustration level, intolerance to bright lights and noise, ringing in ears,
anxiety/depression, sleep disturbance
Changes:
Rapid, short lived neuro disfuntion, resolves spontaneously
Neuopathologic functional changes
No imaging changes, we only look for hemorrhaging
Most resolve in 7-10 days,
Kids longer on safe side, provide cognitive rest from school, videogames, etc.
Grade I: Confusion, no LOC, resolve in <15 min.
Grade II: same as above for >15 minutes
Grade III: Any loss of consciousness
Sideline Evaluation:
Orientation: time, place, person, situation
Concentration: count backwards, month of year backwards
Memory: previous contest, 3 words and 3 objects at 0 and 5 min., recent event
External: 40 yard sprint, 5 push ups, 5 sit ups, 5 knee bends (no signs)

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 Pupils: symmetrical and reactive

Coordination: Finger to nose, tandem gate
Sensation: finger to nose-eyes closed; Romberg

MRI after one week; PET scan

Decreased glucose uptake at site; K+ transport reduced = reduced brain fxn
Activity delays recovery
Look for Neuropsychiatric evaluation

Second Impact Syndrome:

2nd impact during a concussion
1st impact confuses the brain, 2nd loses ability of blood flow and swelling
Post Concussion Syndrome:
Some deficits are permanent
Concussions are cumulative
Cognitive deficits biggest indicator of poor outcome
Complex Regional Pain Syndrome (CRPS)
Diagnosis:
UE and LE involvement, Male common, 40-60
Blunt trauma and fx = leading causes
Crush injuries, burns, amputations, arthroscopy
Repetitive trauma and overuse injuries
ATYPICAL may show limited ROM or spasms with little/no pain
Clinical:
50% atypical
Previous noxious stimulus, Exaggerated response to painful stimulus;
Pain outlasts healing phase
Sleep disturbances, pain worse at night
Myospasms or hypertonicity

Neurological, psychological & functional impairment (spread to extremities)

Distal extremities and diminishes proximal
May spread distal or proximal, unrelated areas
Does not follow anatomy/dermatomes
Disuse atrophy second to pain (joints stiff, contractures and osteopenia)

Narcotics dont help, look like seeking drugs

Residual pain from damage to major nerve root
Cold weather or changes make worse, intolerance to cold
Anxiety, depression, hopelessness in chronic episodes
Stage I:
Days/weeks after, BURNING and pain, frequent hypersthesia
Movement worsens the pain, edema, tender, muscle spasm

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 warm & red, or cool and pale

Stage II:
Hyperesthesia, paresthesia or allodynia
Edema spreads to adjacent joints, muscle wasting
Skin cold, pale, moist; hair thick and course, brittle nails
Stage
III:

Resist treatment, diffuse allodynia, burning, aching, throbbing

exposure to cold, draft, damp aggrevates
Immobile limb, subcutaneous atrophy, contractures
Skin smooth, shiny, cold, damp
anxious, entative, depressed
Diffuse osteoporosis on x-ray
CRPS type I = RSD,
CRPS type II = develops after nerve injury
Confirm:
sympathetic block stops pain immediately, but not stop radicular or nociception
Block and restore ROM
MARFANS SYNDROME
Affects: skeleton, eyes, heart and blood vessels, nervous system, lungs, skin
Increased ligament injury, myalgias and arthralgias
1-10,000; no sexual or race preference, 78% inhereted
Clinical: (top to bottom)
Taller than normal, high arched palate, thin narrow head
Eyes: Myopia, lens dislocation, detached retina
Arm span > height, arachnodactyly (fingers)
Sternal deformity, Kyphoscoliosis, Hernias, Hyperflexible
Genu recrvatum, flat feet
Cardiovascular:
Dilated aortic root, aortic regurgitation, dissecting aortic aneurysm
mitral valve prolapse
MC death = aortic dissection and rupture
Exams:
Cross finger sign = cross thumb across palm with overlap
Wrist wrap around sign = thumb and index finger around wrist with overlap
Complete family history and physical exam
Split lense evaluatoin and echodardiogram
NO max. or dynamic cardiac stress, athletic activity or contact sports

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