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LESSON #12
Images of most body systems: tutorials, lab exercises & examinations, “case of the
week,” & links to other sites
http://telpatah2.med.utah.edu/WebPath/webpath.html
Variety of topics
http://www.mayohealth.org
Assess for:
Symmetry
Muscle strength
Range of motion
Balance
Coordination
Gait
Reflexes
Aging :
Fibrosis of connective tissue
Increased collagen
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Decreased water
Tendons less elastic
Decreased reaction time
Increased bone reabsorption (increased risk for fractures)
Decreased bone density (increased risk for fractures)
Deterioration of cartilage around joints (decreased ROM, stiffness, pain)
Systemic: Examples:
RA (rheumatoid arthritis)
Systemic Lupus Erythematosis
Polymyositis
Symptoms:
Inflammation
Fever
Changes in lab values
Chronic weakness
Joint stiffness
Localalized: Examples:
Lumbar strain
Tennis elbow
Symptoms:
History of trauma
Inflammatory response
Erythema
Edema
Restriction of motion
Pain
Structure
Bone: Collagen fibers: gel of calcium & phosphate
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• Movable: most common
• Hinge (flexion – extension)
• Pivot (rotation on one axis)
• Condyloid (2 axis movement)
• Saddle (2 axis, similar to condyloid)
• Ball & socket (multiple axis & rotation)
• Plane joint (multiple axis, more limited)
Muscle Strength: May be measured with range of motion, and either passive or active
History:
PMH
Viral illness or chronic illness
Limitation of movement
Spasm
Precipitating factors: injury, activity
Stress
Numbness/tingling
Crepitus
Injury (sensation, mechanism of injury, direct trauma, twist,
pain, swelling, trauma to nerves or soft tissues, fractures
Employment
Exercise
Weight
Nutrition
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Cigarette use
Medications
Breast implants (autoimmune responses, especially in joints)
Assessment: Consider:
full exposure, symmetry & diameter measurements
Gait
Spine
Joint Pain:
Inflammation Present:
Yes - RA, SLE
No – Osteoarthritis
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more common with RA, SLE
Osteoarthritis:
Rheumatoid Arthritis:
Laboratory Assessment:
• CBC & differential (H & H may be low)
• Erythrocyte sedimentation rate (inflammatory process)
• Urinalysis
• RF: Rheumatoid Factor titer
(a macroglobulin type antibody, elevated in rheumatoid arthritis)
• ANA: Antinuclear Antibodies
(an immunofluorescent test for differential diagnosis of
rheumatic disease, for detection of antinucleoprotein factors
& patterns associated with several autoimmune diseases,
particularly systemic lupus erythematosis (SLE)
Risk Factors:
Repetitive lifting
Exposure to vibration
Cigarette smoking
Osteoporosis - Spinal stenosis
Obesity
Lack of exercise
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Increased age
Differential Diagnosis:
Acute lumbar-sacral sprain
Postural backache
Lumbar sick syndrome
Osteoarthritis
Irritable bowel syndrome
Urinary disorders (including bladder, kidney, prostate)
GYN disorders
Ankylosing spondylitis (chronic inflammatory, AM stiffness,
limitation of spinal movement)
Tumors
Exam:
Heal - toe talking toe & heel walking may help; differentiate some neuropathies
(tandem) Example: difficulty walking on heel (L5)
difficulty walking on toes (S1)
Motor strength
Sensation
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Hip ROM Restricted abduction is a common in osteoarthritis
Restricted hip rotation is an early sign of
degenerative hip disease
External hip rotation limitation, followed by reduced
abduction & adduction, then flexion
Trendelenburg test: positive test indicates disorders of femur, hip or
related muscle groups
With repetitive trauma: progressive degeneration of nuclei pulposus leading to protrusion or complete
extrusion of disc into n neural canal
• 95% at 4 & 5 L spaces
• Most common between 3rd & 4th decades
Knee:
• Largest joint in body
• No intrinsic stability, depends on ligaments, muscles, menisci & capsule for support
• Medial collateral ligament: limits abduction
• Lateral collateral ligament: limits adduction
• Anterior cruciate ligament: prevents anterior knee displacement
• Posterior cruciate ligament: prevents posterior knee displacement
• Quadriceps: control extension & prevent hip dislocation
• Hamstrings: support tendon for ankle & lower leg
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• Meniscus: cartilage above tibia & fibula, facilitate knee movement
Knee Injuries:
Strains & sprains of the knee are often caused by forces that create abduction of the leg
at the knee, with hyperextension of the knee or by direct blows to the knee
• Strain: injury mostly to muscles
• Sprain injury to supporting ligaments, tendons & muscles
Exam:
• Lateral Stability
• Valgus & varus stress tests: (lateral & medial collateral ligaments)
• Injury to Meniscus: Normal rotation of tibia is forcibly prevented as knee is flexed or extended
Simple twisting injury to knee can tear meniscus
Medial meniscus injuries 10 X more common than lateral meniscus injuries
Clinical features:
Inability to flex knee
Knee pan - well localized
Swelling – gradual (24 – 48 hours: longer than tendon injury)
Locking of knee (or clicking)
Popping or tearing
Walking up & down stairs difficult
Joint effusion
Limited ROM & weight bearing
Positive McMurray
Normal X-ray
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Treatment: Rest
Immobilization of knee
Ice
Elevation
ROM - quadriceps strengthening exercises
Possible surgery
R – rest I - ice
I – ice C - compression
C – compression E - elevation
E – elevation S – stability
Treatment: R
I
C
E
NSAIDS
Osgood-Schlater Disease:
Involved the growing tibial tuberosity
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Adolescents, 8 - 15 years
Bilateral
Males > Females
Self-limited
Clinical features:
Local pain & swelling over tibial tuberosity
Pain with stair walking, exercise, squatting on knee
Lateral x-ray may release variable degrees of separations & fragmentation
of tibial epiphysis
Clinical features:
Numbness/Tingling of long & index fingers
+ Tinel & Phalan signs
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