Office Orthopaedics

Office Orthopedics for Primary Care: Diagnosis

Copyright © 2006 Elsevier Inc. All rights reserved

Author(s): Bruce Carl Anderson, MD

ISBN: 978-1-4160-2207-7

Copyright, Page iv

Dedication, Page v

Preface, Pages vii-viii

Acknowledgments, Page ix

Chapter 1 - Neck, Pages 1-18

Chapter 2 - Shoulder, Pages 19-49

Chapter 3 - Upper Back Pages 50-65

Chapter 4 - Elbow, Pages 66-81

Chapter 5 - Wrist, Pages 82-100

Chapter 6 - Thumb Pages 101-117

Chapter 7 - Hand Pages 118-136

Chapter 8 - Chest Pages 137-148

Chapter 9 - Lumbosacral Spine, Pages 149-171

Chapter 10 - Hip, Pages 172-194

Chapter 11 - Knee, Pages 195-221

Table of Contents

Chapter 12 - Ankle Pages 222-249

Chapter 13 - Foot Pages 250-276

References, Pages 277-293

Index, Pages 295-301

1600 John F. Kennedy Blvd.Ste 1800Philadelphia, PA 19103–2899

ISBN 987-1-4160-2207-7OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS ISBN 1-4160-2207-4Copyright © 2006 by Elsevier Inc.

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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broadenour knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate.Readers are advised to check the most current information provided (i) on procedures featured or (ii) by themanufacturer of each product to be administered to verify the recommended dose or formula, the methodand duration of administration, and contraindications. It is the responsibility of the practitioners, relying ontheir own experience and knowledge of the patients, to make diagnoses, to determine dosages and the besttreatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent ofthe law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to personsor property arising out or related to any use of the material contained in this book.

Library of Congress Cataloging-in-Publication DataAnderson, Bruce Carl.

Office orthopedics for primary care: diagnosis / Bruce Carl Anderson.—1st ed.p. ; cm.

ISBN 1-4160-2207-41. Orthopedics—Diagnosis. 2. Primary care (Medicine) I. Title.[DNLM: 1. Musculoskeletal diseases--diagnosis. 2. Family Practice—methods. 3.Fractures—diagnosis. WE 141 A545oa 2006]RD732.A52 2006616.7′075—dc22

2005049901

Acquisitions Editor: Rolla CouchmanDevelopmental Editor: Dylan ParkerDesign Direction: Karen O’Keefe Owens

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the pioneering work of E C Kendall, biochemist and researcher at the

Mayo Clinic of Rochester, Minnesota, and winner of the 1950 Nobel Prize in Biochemistry

for the synthesis of cortisone from bile acids.

P R E F A C E

This is the first edition of Office Orthopedics for PrimaryCare: Diagnosis, the companion book to Office Orthopedics forPrimary Care: Treatment. This two-volume set provides theclinician with the concise information to diagnose, treat,and determine the need for surgical referral on the mostcommon conditions affecting the musculoskeletal system.Emphasis has been placed on those conditions that aremost likely to present to the primary care physician, includ-ing the most common joint and soft tissue diagnoses as wellas the noncatastrophic, uncomplicated fractures that fre-quently present to the primary care office.

The book has been formatted in a unique manner, de-pending on the needs of the clinician and the time allottedfor evaluation of the musculoskeletal complaints. For theclinician interested only in screening the patient, each sec-tion begins with the most effective maneuvers that allow arapid and effective triage of the patient to radiographic orlaboratory testing or general treatment guidelines. By con-trast, for the clinician interested in the complete manage-ment of the patient’s musculoskeletal complaints, thescreening maneuvers of each section are followed by the de-

tailed examinations that allows for a definitive diagnosisand subsequent specific treatment guidelines.

Traditionally local musculoskeletal diagnosis has reliedupon combining the patient’s description of pain, thedemonstration of loss of function, and the results of phys-ical examination with the changes either on plain radio-graphs or specialized imaging (MRI, CT, bone scanning)to distinguish involvement of the joint from involvementof the soft tissues or bone. In general, this is an effectiveapproach when evaluating patients with degenerativearthritis or advanced tendon and ligament injuries wherecharacteristic changes on plain radiographs or specialimaging are unequivocal. However, the combination ofhistory, examination, and imaging fails to accurately diag-nosis up to one-third of joint and soft tissue conditions(see the table below) because of the nonspecific nature ofthe complains, the overlap of physical signs, and the lackof diagnostic changes on radiographic testing. Previouspublications have failed to address this inadequacy byfailing to emphasize the importance of diagnostic localanesthetic block and synovial and bursal fluid aspiration

TABLE 1 SUMMARY: DIAGNOSTIC TESTING FOR 183 LOCAL MUSCULOSKELETAL CONDITIONS

JOINT X-RAY CT/MRI BONE SCAN EXAM LOCAL ANESTHESIA ASPIRATION SURGERY

Neck 3 4 — 3 1 — —

Shoulder 6 2 — 3 3 3 —

Upper Back 3 3 — 3 1 — —

Elbow 3 1 — 2 3 6 —

Wrist 4 1 1 2 2 5 —

Thumb 2 — — 2 3 — —

Hand 3 — 1 8 1 — 1

Chest 1 — 1 1 4 2 —

Back 4 5 1 2 2 — —

Hip 5 1 3 2 4 2 —

Knee 5 2 — 1 5 5 2

Ankle 7 — 2 8 2 1 —

TOTALS 47 21 10 40 37 25 3

26% 11% 5% 22% 20% 14% 2%

This table summarizes the diagnostic testing used to confirm the most common musculoskeletal conditions described in this book, the conditions thatpresent to the primary physician in an outpatient setting. When more than one method of confirming the diagnosis is possible, the most reliablemethod was chosen. Local anesthesia refers to confirming the diagnosis by the accurate placement of lidocain or bipivacaine within the joint, bursa,or along the tissue plane adjacent to the tendon, ligament, or nerve. Aspiration uniformly refers to the removal of joint or bursal fluid for laboratoryanalysis.

and analysis. For example, anserine bursitis frequentlycomplicates medial compartment osteoarthritis of theknee. Both conditions are characterized by impaired gait,medial knee pain, and medial knee tenderness. Neitherplain radiographs or special imaging effectively distin-guishes one from another. However, pain relief and improved ambulation after placing local anesthetic eitherintra-articularly or intrabursal is the only means of effec-tively distinguishing the role of each. Similarly, local anes-thetic block is often necessary to distinguish trochantericbursitis from L4-5 radiculopathy, rotator cuff tendonitisfrom the referred pain of C4-5 radiculopathy, de Quervain’stenosynovitis from carpometacarpal osteoarthritis, and soforth.

VIII PREFACE

Table 1 also emphasizes the relative infrequent need to re-fer to the orthopedic surgical service for specific diagnostictesting. Only 2 percent of diagnoses require surgical inter-vention to complete the diagnostic workup; namely thoseconditions that require arthroscopy for confirmation(meniscal tear, ACL tear, and osteochondritis dissecans).

Hopefully, this new edition will provide the practitionerwith the means to manage the wide range of conditions thatcommonly affect the musculoskeletal system. With a moreaccurate means of diagnosis available to the clinician moreeffective and timely provided treatment will result in betterpatient outcomes.

Bruce Carl Anderson, MD

A C K N O W L E D G M E N T S

This book represents the outgrowth of 27 years of postres-idency education and clinical experience with over 50,000local procedures that would not have been possible withoutthe support and encouragement from many sources. I wishto thank all the members of the departments of medicine,family practice, physiatry, neurosurgery, and surgical ortho-pedics at the Sunnyside Medical Center, especially Dr. IanMacMillan of the department of medicine for his supportand assistance in developing the medical orthopedic depart-ment and the surgeons of the department of orthopedics, Dr.Steven Ebner, Dr. Edward Stark, and Dr. Stephen Groman,for their stimulating feedback. I also wish to thank my ex-tremely capable physician assistant, Linda Onheiber, for hersteady contributions to the medical orthopedic department,and all the medical residents of the graduating classes of2003 and 2004 at Oregon Health Sciences University,

Eastmoreland Osteopathic Hospital, and Emmanual-Legacyand Providence teaching hospitals, for their constant encour-agement, contributions, and critical appraisal of the contentof the book. I also wish to thank the medical directors of thevarious Portland, Oregon, teaching hospitals for their sup-port; namely, Dr. Nancy Loeb at Sisters of Providence St. Vincents hospital, Dr. Steven Jones at Emmanual-Legacyhospital, and Dr. Don Girard at the Oregon Health SciencesUniversity. Lastly, I wish to thank Dr. David Gilbert, direc-tor emeritus of the Sisters of Providence Glisan hospital—myinternal medicine residency director—for his stimulation toexcellence, his encouragement to examine ever deeper intoclinical problems, and his support and inspiration in my re-turn to clinical research.

Bruce Carl Anderson, MD

CHEST IX

1

CHAPTER 1: NECK

DIFFERENTIAL DIAGNOSIS

Diagnoses

Cervical strain (most common diagnosis)StressWhiplash and related injuriesDorsokyphotic postureFibromyalgia

Osteoarthritis of the neckReactive cervical strain

RadiculopathyVertebral body fractureSpinal cord injury or tumor

Cervical radiculopathyForaminal encroachment

Herniated nucleus pulposusEpidural process

Thoracic outlet syndromeCervical rib

Greater occipital neuralgia

Temporomandibular joint syndrome

Referred painCoronary arteries

Takayasu’s arteritisThoracic aortic aneurysmThyroid disease

Confirmations

Socioeconomic or psychological issuesMotor vehicle accident or head and neck traumaTypical in older adults or in patients with depressionConfirmation by exam: multiple trigger points,

normal labX-ray: cervical series (lateral view)Underlying spinal column, nerves, or cord are

threatenedNeurologic testingBone scan or magnetic resonance imaging (MRI)MRI

X-ray: cervical spine x-rays (oblique views); electromyography (EMG)

MRIMRI

Nerve conduction velocity (NCV) and EMGX-ray: cervical series (anteroposterior view)

Local anesthetic block

Exam or local anesthetic block

Electrocardiogram, creatine phosphokinase, angiogram

Erythrocyte sedimentation rate (ESR), angiogramChest x-rayThyroid-stimulating hormone, thyroxine, ESR,

thyroid scan

2 OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

INTRODUCTION Cervical strain and osteoarthritis arethe two dominant conditions affecting the neck. Cervicalstrain caused by tension, stress, dorsokyphotic posture, orwhiplash is a nearly universal condition early in life. In laterlife cervical strain is still common but rivaled by os-teoarthritis affecting the facet and paravertebral joints, alsoa nearly universal condition. In the sixth and seventhdecades these two processes combine to cause the progres-sive stiffness and forward position of the head typical ofolder adults.

The diagnosis of an uncomplicated cervical strain causedby tension, stress, poor posture, or mild whiplash is not dif-ficult. Signs and symptoms are limited to the supportingmuscles of the neck, the trapezius and paraspinal muscles.The muscles are tender, the range of motion is reduced bymuscular spasm, and there is a conspicuous absence of bonytenderness and radicular signs in the upper extremities. Thisis in stark contrast to reactive cervical strain, which is the di-rect result of an underlying threat to the spinal column.Bony disorders, spinal nerve compression, or the rare con-ditions affecting the spinal cord directly cause severetrapezial and paraspinal muscle spasm. The challenge to theprimary care provider is to distinguish simple cervical strainfrom the severe muscular spasm that is a reaction to a seri-ous underlying neurologic process.

Cervical arthritis is the second most common neck con-dition, increasing in prevalence and degree with advancingage. Symptoms can range from simple stiffness and loss ofrange of motion to radiculopathy from foraminal encroach-ment and spinal cord compression from spinal stenosis.Osteoarthritic wear occurs at the paravertebral facet jointsand between the lateral margins of the vertebral bodies, theLuschka joints.

Both cervical strain and cervical osteoarthritis are in-volved in the development of cervical radiculopathy, orcompression of the spinal roots or nerves. Ninety percent ofspinal nerve compression results from neuroforaminal nar-rowing by osteophyte overgrowth, foraminal encroachmentdisease. With this threat to the spinal nerve, reactive cervi-cal strain develops, compounding the nerve irritation. Only10% of cervical radiculopathy is caused by a herniated nu-cleus pulposus (HNP), whereas 90% of radiculopathy in thelumbar spine is caused by HNP. Spinal stenosis is the mostdramatic form of cervical radiculopathy.

Upper extremity neurologic impairment can also resultfrom brachial plexus nerve compression or inflammation.Loss of upper extremity sensation or motor function can becaused by thoracic outlet (cervical rib, hypertrophy of thescalenus anticus or pectoralis minor, or Pancoast’s tumor) orbrachial plexopathy.

Greater occipital neuritis is a unique problem arisingfrom the neck. It is also related directly to cervical strain.The greater occipital nerve must traverse the upper cervicalmuscles to enter the subcutaneous tissue on its way to in-nervating the scalp. Persistent muscle spasm is the principalirritation of this nerve.

Pain referred to the neck is uncommon. Intrinsic shoul-der conditions can incite reactive cervical strain. Diseases ofthe heart, major vessels of the chest, or thyroid (coronaryartery disease, Takayasu’s arteritis, thoracic aortic aneurysm,thyroid disease) will cause pain in the jaw or, rarely, neckpain.

SYMPTOMS Patients complain of neck pain, musclespasm, stiffness or loss of range of motion, or upper ex-tremity sensorimotor symptoms reflective of radiculopathy.Most patients describe a combination of symptoms.Patients with moderate to severe cervical strain may experi-ence reversible sensory radiculopathy. Conversely, patientswith radiculopathy often describe symptoms reflective ofthe accompanying reactive cervical strain.

Neck pain is the most common presenting symptom. Itis most often described at the base of the cervical spine oralong the upper border of the trapezius muscle. Reactivecervical strain—irritation and spasm of the muscles of theneck or upper back—is the principal cause of this pain.Although cervical strain is most commonly caused by theordinary emotional and physical stresses of everyday life,poor posture, or poor sleeping habits, it is also the body’s fi-nal common pathway for any process that threatens the in-tegrity of the spinal column, spinal nerves, or spinal cord;thus, cervical strain often accompanies whiplash, arthritis ofthe cervical spine, or radiculopathy.

Patients also complain of neck stiffness. Varying degreesof neck stiffness often accompany cervical strain. Moderateto severe neck stiffness is typical of cervical degenerativearthritis; facet and paravertebral joint osteophyte formationand articular cartilage thinning correlate directly with thesymptoms of stiffness and the measurable loss of neck flex-ibility, most notably in rotation and extension.

Numbness, tingling, and pain down the arm are thecommon symptoms of cervical radiculopathy (“I think Ihave a ‘pinched nerve’”). Cervical radiculopathy is causedby spinal nerve compression due to cervical arthritis in 90%of cases. As the paravertebral and facet joints gradually wear,bony osteophytes gradually enlarge, compromising the exitneuroforamina (foraminal encroachment). If the overall sur-face area is reduced by 50%, the spinal nerve is at risk. Ittakes only a small degree of cervical strain to incite (painand paresthesias) or impair (hypesthesias or motor weak-ness) the spinal nerve. Cervical radiculopathy is caused by aherniated disk in 10% of cases (younger, more acute, andgreater degrees of motor involvement on average), and lessthan 0.1% is caused by spinal cord encasement by large os-teophytic bars (spinal stenosis).

Some patients complain of a unilateral headache withnumbness or tingling of the scalp. This unique headachepattern is the result of intense or chronic paraspinal musclepain at the base of the neck. Greater occipital neuralgia re-sults from the irritation of this sensory nerve as it penetratesthese paraspinal muscles at the base of the skull.

Lastly, involvement of the vertebral bodies by fracture,tumor, or infection typically causes severe localized neckpain and dramatic cervical muscle spasm.

EXAMINATION The examination of the neck beginswith the observation of the general movement of the head,neck, and eyes. The posture and general movements of theneck, whether rigid and guarded or loose and free, should beconsistent during the interview phase as well as during theactual examination. Lack of consistency can be a clue to ma-lingering in the case of whiplash or cervical radiculopathythat is under litigation. Measurement of the range of motionof the neck, especially neck rotation and lateral bending, is

NECK 3

used to assess the general flexibility of the neck; loss ofrange of motion in these directions is the best indication ofabnormal neck function. For example, when neck move-ment is impaired, endpoint stiffness is demonstrated, andmild to moderate pain is reproduced, cervical osteoarthritisis the likely diagnosis. Next, the supporting muscles of theneck—the trapezius and paraspinal muscles—are examinedfor local tenderness, spasm, and their effect on neck flexi-bility. Finally, the Spurling maneuver, the manual verticaltraction maneuver, and a detailed upper extremity neuro-

1. Observe the movement of the head, neck, and eyes.2. Perform and estimate neck rotation and lateral

bending.3. Palpate the paraspinal and upper trapezial muscles

for tenderness and spasm.4. Estimate the degree of reactive cervical muscle.5. Determine the degree of cervical radiculopathy.

SCREENING EXAMINATION OF THE NECK

logic exam are performed to determine the presence of cer-vical radiculopathy.

Patients with normal range of motion, normal upper ex-tremity neurologic function, and nontender neck musclesshould undergo medical examination of the heart, upperchest, and thyroid to evaluate for possible referred pain tothe head and neck area.

By contrast, the approach to the patient who has sus-tained serious head or neck trauma differs dramatically fromthe typical outpatient evaluation. If the patient has sus-tained significant head or neck trauma, the integrity of thevertebral column is assessed by testing sensation and move-ment in all four extremities, palpating the spinous processfor alignment and local tenderness, and testing range ofmotion of the neck. If the traumatized patient has focal ab-normalities, aggressive radiographic testing for occult verte-bral fracture or subluxation or paravertebral hemorrhagemust be performed.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL NECK FUNCTION ANDDIFFERENTIAL DIAGNOSIS

POSTURE AND GENERAL MOVEMENT

SUMMARY: The patient’s posture and general man-ner of movement of the head, neck, and eyes canbe an important clue to underlying neck disorders.

MANEUVER: The consistency of the patient’s postureand the general movement of the head, neck, andeyes are noted with and without examiner distraction.

INTERPRETATION: Patients with depression andolder adults present with a dorsokyphotic posture(forward head position, partially flexed neck,slumped shoulders). Sluggish movement or generalstiffness is characteristic of osteoarthritis, cervicalstrain, and fibromyalgia. Torticollis reflects acutemuscular spasm, often from an HNP. Extremeguarding or apprehension is indicative of necktrauma or large disk herniation.

FIGURE 1–1. Posture and general movement of the headand neck.

BOX 1-1


PASSIVE ROTATION OF THE NECK

SUMMARY: Range of motion testing in rotation isthe single most important clue to an underlyingneck condition. The paravertebral and facet jointsof the vertebral bodies, the odontoid process, andthe supporting muscles allow the neck to rotate anaverage of 90 degrees to either side.

MANEUVER: The patient is asked to relax. The ex-aminer places one hand on the shoulder and onehand on the chin. The neck is passively rotated tothe affected side, noting the degrees of rotationand endpoint stiffness.

INTERPRETATION: Rotation less than 90 degrees isabnormal. X-rays and neurologic testing of the up-per extremities are necessary to determine the un-derlying cause of the loss of flexibility (osteoarthri-tis, injury to the vertebral column, cervicalradiculopathy, and severe cervical strain).

FIGURE 1–2. Measurement of passive rotation of the neck.

PALPATION

SUMMARY: The superior portion of the trapeziusmuscle is the most commonly irritated neck muscle.The upper portion of the trapezius muscle originatesfrom the seven spinous processes and the distal as-pect of the acromial process.

MANEUVER: The superior trapezial muscle is pal-pated for local tenderness and spasm approxi-mately halfway between the acromion and spinousprocesses of the neck.

INTERPRETATION: Local muscular tenderness can re-sult from trauma (a direct blow), but the majority ofcases are caused by reactive cervical muscularstrain (cervical muscular strain, fibromyalgia,whiplash, stress, and poor posture).

FIGURE 1–3. Palpation of the upper trapezial muscle.

NECK 5

SPURLING MANEUVER

SUMMARY: The Spurling maneuver attempts to re-produce the patient’s symptoms by further compres-sion of the nerve as it passes by the vertebral diskor through the neuroforamina. Each spinal nervemust pass by the lateral portion of the cervical diskand through its corresponding bony canal, the neu-roforamina. Nerve compression is caused most of-ten by bony osteophytes reducing the neuroforam-ina opening by 50% or by a herniated nucleuspulposus.

MANEUVER: Several positions of the head are usedto provoke nerve irritation, starting with the head inneutral position. The examiner taps or pressesdown on the top of the head. If this is unsuccessful,the maneuver is repeated with the head rotated, hy-perextended, or bent to the side.

INTERPRETATION: This is the only maneuver that isused to reproduce the patient’s radicular pain. It isvery specific but lacks sensitivity.

FIGURE 1–4. Spurling maneuver to reproduce the lancinat-ing pain of cervical radiculopathy.

FOCAL TENDERNESS

SUMMARY: The greater occipital nerve is a puresensory nerve providing sensation to half the scalp.The greater occipital nerve passes through the up-per cervical muscles to enter the subcutaneous tis-sue of the back of the head. Chronic cervical mus-cle strain causes compression and irritation of thenerve, leading to a unilateral headache with ac-companying paresthesias.

MANEUVER: Local tenderness is present 1 inch be-low the base of the skull and 1 inch lateral to themidline. Tapping over the nerve (Tinel sign) may in-duce paresthesias.

INTERPRETATION: Greater occipital neuritis shouldbe considered when patients complain of a unilat-eral headache that is accompanied by sensory ab-normalities of the scalp.

FIGURE 1–5. Focal tenderness of the greater occipital nerve.


PALPATION OF THE TMJ

SUMMARY: Local tenderness can be elicited eitherin front of the tragus of the ear or in the externalcanal. In order to distinguish the pain arising fromthe TMJ from disorders of the ear, the patient isasked to open and close the jaw.

MANEUVER: Local tenderness is palpated either justanterior to the tragus or with the examiner’s fingerplaced in the outer aspect of the external canal.Firm pressure is applied, and the patient is asked toopen and close the jaw.

INTERPRETATION: The pain and local tenderness ofotitis externa and otitis media should not be aggra-vated by jaw movement. Sialadenitis of the parotidgland is characterized by diffuse tenderness andswelling in a triangular area anterior and inferiorlyto the ear.

FIGURE 1–6. Palpation of the TMJ comparing one side withthe other.

ONE-MINUTE SCREENING EXAM:MANAGEMENT OPTIONS

TRIAGE TO X-RAY For patients with a history oftrauma, those who are at risk of bony injury, those in whomradiculopathy is suspected, or those who have had chroniccervical strain:

• Order a cross-table lateral with the patient left in the neckcollar if there has been a severe injury to the head or neckor the patient has sustained a concussion (fracture or dis-location). Complement this with an MRI if there has beensevere neck trauma and the exam demonstrates either fo-cal neurologic deficits or focal bony tenderness (occultvertebral fracture).

• Order routine cervical spine series for patients with morethan 25% loss of range of motion (osteoarthritis, severecervical strain, early radiculopathy).

• Order routine cervical spine series for all patients withradiculopathy (90% of cervical radiculopathy is caused bynarrowing of the exit foramina [foraminal encroachmentdisease]).

• Order a lateral view of the neck to assess the alignment ofthe cervical spine in patients with chronic cervical strain,fibromyalgia, and persistent whiplash symptoms.

TRIAGE TO THE LAB For the rare patient with fever,acute pain, exquisite tenderness, and signs of upper extrem-ity neurologic abnormalities (i.e., acute onset of radicu-

lopathy), order a complete blood cell count, blood cultures,and ESR (possible osteomyelitis or epidural abscess).

CONSIDER A BONE SCAN For patients with local-ized vertebral body tenderness, a recent history of injury,and equivocal cervical spine x-rays (acute vertebral com-pression fractures).

CONSIDER AN MRI For patients with acute cervicalradiculopathy and rapidly developing neurodeficit (epiduralabscess), for patients with cervical radiculopathy with nor-mal cervical series x-rays (disk herniation), and for patientswith cervical radiculopathy and a known history of metasta-tic disease (epidural metastasis).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate neck pain, neck stiffness butpreserved rotation to 90 degrees (able to look down theshoulder), tightness and spasm of the paraspinal or trapezialmuscles, but no radicular complaints (radicular pain, pares-thesias, or loss of upper extremity strength).

• Avoid stressful situations.• Attend to improved posture.• Apply ice to the muscle groups in spasm.• Perform daily passive stretching exercises in rotation.• Recommend a muscle relaxer over 7 consecutive nights.• Use a soft Philadelphia collar during the daytime (optional).

NECK 7

DETAILED EXAMINATION: SPECIFIC NECKDIAGNOSES

Perform a detailed examination of the neck if the patient haspersistent or chronic symptoms and one or more of the fol-lowing signs are present: moderate to severe neck pain andstiffness, focal spinous process tenderness, 40% to 50% lossof range of motion, intense paraspinal or trapezial musclespasm (torticollis), or radiculopathy with motor involvement.

REACTIVE CERVICAL STRAIN The primary function of the paracervical and trapezial muscles is to support and providemovement for the head and neck. However, their secondary func-tion is to react to any threat to the integrity of the cervical column,spinal cord, or spinal nerves; reactive cervical strain is the neck’sprotective mechanism whenever the structures of the neck are in jeopardy.

PALPATION

SUMMARY: The superior portion of the trapezialmuscle is the most common neck muscle involved inacute and chronic cervical strain.

MANEUVER: Palpate the superior trapezial musclealong its entire superior border, with emphasishalfway between the acromion and spinousprocesses of the neck. Assess the degree of localtenderness, focal muscle spasm (“knots”), and itsoverall tone (soft, moderate tension, hard).

ADDITIONAL SIGNS: Palpate the paraspinal mus-cles 1 to 2 inches from the midline for tenderness.Palpate the levator scapula and rhomboid musclesfor tenderness. Palpate the subscapular bursa at thesuperomedial angle of the scapula for tenderness.

INTERPRETATION: Cervical muscular strain resultingfrom poor posture, stress, or unaccustomed use canbe graded by the number of muscle groups affected.Fibromyalgia, whiplash, and reactive cervical strainsecondary to an underlying process affecting thespinal column involve multiple muscle groups.

FIGURE 1–7. Palpation of the upper trapezial muscle in reactivecervical strain.

LOCAL INTRAMUSCULAR ANESTHETIC BLOCK

SUMMARY: A tentative diagnosis of an uncompli-cated case of cervical strain is based on the palpa-tion of the supporting muscles of the neck. In orderto distinguish simple cervical strain from subscapu-lar bursitis or radicular pain referred from the lower cervical roots, local intramuscular anesthetic blockis performed.

NEEDLE: 11⁄2 inch, 22 gauge.

DEPTH: 1 to 11⁄2 inches.

VOLUME: 3 to 4 cc anesthetic, 1 mL D80, or both.

NOTE: Lightly advance the needle until the firm, rub-bery tension of the outer fascia of the trapeziusmuscle is encountered. Place 1 cc anesthetic at theinterface of the subcutaneous fat and the fascia be-fore entering the body of the muscle. If corticos-teroid is used, avoid the triamcinolone derivatives.Kenalog and Aristospan are much more likely tocause atrophy of the muscle or the overlying subcu-taneous tissue than methylprednisolone.

FIGURE 1–8. Local intramuscular anesthetic block of thetrapezius to confirm of cervical strain.


OSTEOARTHRITIS OF THE NECK Age takes its toll on thefacet and the paravertebral joints of the neck, leading to a varietyof conditions, including the characteristic dorsokyphotic posture,

simple stiffness and pain from a gradual loss of rotation, osteoarthritis, and cervical radiculopathy caused by foraminal encroachment or spinal stenosis.

PASSIVE ROTATION OF THE NECK

SUMMARY: The paravertebral and facet joints of thevertebral bodies, the odontoid process, and thesupporting muscles allow the neck to rotate an av-erage of 90 degrees. Progressive osteoarthriticwear of the paravertebral joints of Luschka andfacet joints causes a gradual loss of rotation.

MANEUVER: The patient is asked to relax. The ex-aminer places one hand on the shoulder and onehand on the chin. The neck is passively rotated tothe affected side, and the examiner notes the de-grees of rotation and endpoint stiffness.

ADDITIONAL SIGNS: The patient may describe grind-ing or crunching with the back and forth rotation ofthe neck. With progressive impairment, lateral bend-ing and neck extension may be impaired. Signs ofradiculopathy may be present with foraminal en-croachment. Manual vertical traction typically affordssymptom relief. Vertebral artery flow may be im-paired with severe arthritic changes, causing the pa-tient to feel dizzy with passive extension of the neck.

INTERPRETATION: Rotation less than 90 degrees isabnormal. X-rays and neurologic testing of the up-per extremities are necessary to determine the ex-act cause of the loss of flexibility. Osteoarthritis andsevere cervical strain are the two most commoncauses of loss of rotation.

FIGURE 1–9. Passive rotation of the neck to estimate the de-gree of osteoarthritis of the facet joints and the paravertebral jointsof Luschka.

LATERAL VIEW OF THE NECK

CASE: This is the lateral neck x-ray of a 77-year-oldformer pilot whose sole complaint was neck stiff-ness. He denied experiencing pain down the arm,numbness or tingling of the fingers, or loss ofstrength in the upper extremities. Neck rotationmeasured 60 to 65 degrees (30% loss) with end-point stiffness. The Spurling maneuver was nega-tive, and the neurologic examination of the upperextremities was normal.

DIAGNOSIS: Uncomplicated cervical osteoarthritis.

DISCUSSION: The lateral view demonstrates an exaggerated cervical lordosis, corresponding tothe forward position of the head seen on exam.The disk spaces are uniformly narrowed andmildly irregular. The facet joints are narrowed, hy-pertrophic, and sclerotic. The posterior aspects ofthe vertebral bodies (the joints of Luschka) are hy-pertrophic and sclerotic. The bony osteophytesthat form here are responsible for the foraminalencroachment of cervical radiculopathy.

FIGURE 1–10. Lateral view of the neck to confirm the de-gree of osteoarthritis.

NECK 9

MANUAL CERVICAL TRACTION

SUMMARY: If the Spurling maneuver is negative orequivocal, the diagnosis of cervical radiculopathyis enhanced if manually applied vertical traction al-leviates the patient’s radicular pain. In addition, thismaneuver can be used to assess the patient’s toler-ance of therapeutic traction.

MANEUVER: The head is grasped at the midjawand occiput. The patient is asked to relax the neckmuscles. Gentle vertical traction is performed to as-sess the effect on the patient’s neck pain, stiffness,and radicular pain.

ADDITIONAL SIGNS: See Figure 1–11.

INTERPRETATION: The response to traction is mostimportant in determining the role of physical ther-apy based on traction. A positive response is non-specific. This maneuver will reduce the pain andstiffness of osteoarthritis and cervical strain and theradicular pain of cervical radiculopathy caused byforaminal encroachment.

FIGURE 1–12. Manual cervical traction to assist in the diag-nosis of cervical radiculopathy and to assess the patient’s toleranceto therapeutic home traction.

CERVICAL RADICULOPATHY The diagnosis of cervicalradiculopathy is most often suggested by the patient’s descriptionof a lancinating pain that crosses at least two major joints andthe description of abnormal sensations (paresthesias or hypesthe-

sias) involving selected digits. The neurologic examination isused to define the degree of nerve impairment. Radiographicstudies (plain radiographs or MRI) are used to define the exactanatomic cause.

SPURLING MANEUVER

SUMMARY: The Spurling maneuver attempts to reproduce the patient’s symptoms by further com-pressing the spinal nerve as it passes by the verte-bral disk or through the neuroforamina.

MANEUVER: Several positions of the head are usedto provoke nerve irritation, starting with the head inneutral position. The examiner taps or pressesdown on the top of the head. If this is unsuccessful,the maneuver is repeated with the head rotated, hy-perextended, or bent to the side.

ADDITIONAL SIGNS: Manual cervical traction—theopposite of the Spurling maneuver—may reducethe patient’s pain and sensory complaints. Thenerve root may be tender when one firmly palpatesbetween the transverse and spinous processes.Sensation, reflex asymmetry, muscle tone, en-durance, strength, or bulk may be impaired on neurologic examination of the upper extremities.Signs of reactive cervical strain are nearly alwayspresent.

INTERPRETATION: This is the only maneuver that isused to reproduce the patient’s radicular pain. It isvery specific but rarely positive.

FIGURE 1–11. Spurling maneuver to reproduce the lancinat-ing pain of cervical radiculopathy.


MRI

CASE: This 43-year-old woman complained of anacute onset of arm pain, numbness of the fingers,and stiffness of the neck. The pain radiated fromthe base of the neck, through the shoulder, downthe arm, and into the hand. She experienced con-stant numbness and tingling of the first three digits.Her examination showed paraspinal tenderness be-tween the spinous and transverse processes of thelower neck, endpoint stiffness with guarding whenthe neck was rotated to the affected side, weaknessof elbow flexion, and a diminished bicipital reflex.

DIAGNOSIS: Cervical radiculopathy caused by aC5–C6 disk herniation.

DISCUSSION: Cervical radiculopathy caused by diskherniation should be suspected in the younger pa-tient with acute symptoms, patients with sensorimotorfindings on neurologic examination, or patients withcervical radiculopathy who have a poor response toempirical treatment with cervical traction.

FIGURE 1–14. MRI to evaluate the cervical spine for occult frac-ture, radiculopathy caused by herniated disk, epidural abscess ortumor, or spinal cord disorder.

OBLIQUE VIEWS OF THE NECK

CASE: This radiograph is from a 54-year-old patientwho presented with a gradual onset of numbnessand tingling of the middle fingers of the right hand.Symptoms waxed and waned over a period of sev-eral months. The triceps reflex and muscularstrength were preserved.

DIAGNOSIS: Cervical radiculopathy caused byC6–C7 foraminal encroachment.

DISCUSSION: The spinal nerve is approximatelyone third the size of the foraminal opening. Whenbony osteophytes from the joints of Luschka (arrow)reduce the overall size of the foramina by 50%,nerve compression and irritation are possible. Thispotential nerve irritation is further aggravated bythe accompanying reactive cervical strain (musclespasm generated by the threat to the nerve) or sim-ple strain induced by posture or unaccustomed use.Most cases of reversible radiculopathy probably re-sult from the accompanying cervical strain.

FIGURE 1–13. Oblique views of the neck to confirm forami-nal encroachment (osteophytes reducing the overall diameter of theneuroforamina).

NECK 11

GREATER OCCIPITAL NEURALGIA Irritation or inflam-mation of the greater occipital nerve is characterized by intense lo-cal tenderness at the base of the skull, a unilateral headache, andipsilateral skin sensitivity or paresthesias over the scalp.

PALPATION

SUMMARY: Headaches are a very common accom-paniment of most conditions affecting the cervicalspine, especially cervical strain, osteoarthritis, andradiculopathy. Greater occipital neuralgia presentswith a unique headache pattern characterized by pain and paresthesias limited to one side of the head.

MANEUVER: The greater occipital nerve is palpated1 inch off the midline and approximately 1⁄2 to 1 inch below the base of the skull.

ADDITIONAL SIGNS: Tapping over the nerve(Tinel sign) may induce the scalp paresthesias.Sensory testing over the scalp may be impaired.Signs of cervical strain invariably are present withlocal muscular tenderness, particularly in theparaspinal muscles.

INTERPRETATION: The unilateral headache ofgreater occipital neuritis must be distinguished frommigraine and the headache that accompaniesforaminal encroachment involvement of the upperthree cervical roots.

FIGURE 1–15. Palpation of the greater occipital nerve.

LOCAL ANESTHETIC BLOCK

SUMMARY: Local anesthetic placed just above andjust below the level of the cervical fascia is used toconfirm the direct involvement of the greater occipi-tal nerve and distinguish this unique headache frommigraine and the headache that accompanies up-per cervical root foraminal encroachment.

Enter 1 inch lateral to the midline and 1 inch caudalto the superior nuchal line of the skull (the base ofthe skull).


DEPTH: 1⁄2 to 3⁄4 inch down to the fascia and then anadditional 1⁄4 inch into the muscle.

VOLUME: 3 to 4 cc anesthetic, 1 mL D80, or both.

NOTE: Lightly advance the needle to feel the outerfascia, then enter the body of the muscle. Avoid tri-amcinolone because it increases the risk of muscleor subcutaneous atrophy.FIGURE 1–16. Local anesthetic block to confirm greater oc-

cipital neuralgia.


TEMPOROMANDIBULAR JOINT SYNDROME The tem-poromandibular joint (TMJ) can be injured by trauma to thejaw or face, inflammed in the patient with hematoid arthritis, orirritated by the chronic effects of stress (high muscle tone, clenching

of teeth, or grinding of the jaw at night). Patients complain of jawpain, ear pain, or difficulties with mastication. The diagnosis isalways suggested when the patient describes pain located at ornear the ear that is aggravated by opening and closing the jaw.

PALPATION

SUMMARY: The TMJ is located directly anterior tothe tragus of the ear and is palpated either at thispoint or from the entrance to the external earcanal.

MANEUVER: The patient is asked to open and closethe jaw as the examiner palpates the area just ante-rior to the tragus and then palpates the joint fromwithin the entrance of the external ear canal.Tenderness and clicking are noted.

ADDITIONAL SIGNS: The maximum mouth opening(measurement between the upper and lower teeth)may be restricted. The pterygoid muscles along theposterior aspect of the alveolar ridge may be ten-der and in spasm. Evidence of abnormal teethwear (grinding) may be present. Anxiety or othersigns of situational stress may be present.

INTERPRETATION: Acute TMJ syndrome typically re-sults from trauma or unusual degrees of chewing.Chronic TMJ syndrome is a manifestation of anxietyand situational stress.FIGURE 1–17. Palpation of the TMJ.


SUMMARY: Ear or facial pain aggravated by chew-ing or opening and closing the jaw does not posea diagnostic challenge. Occasionally, in patientswith subtle pain, concurrent ear disorders, or othercauses of lateral facial pain, anesthesia is neededto confirm involvement of the joint.

With the jaw fully opened, enter the joint 1⁄4 to 3⁄8 inchdirectly anterior to the tragus in the depressionformed over the joint; angle perpendicular to theskin.


DEPTH: 1⁄4 to 1⁄2 inch into the joint.

VOLUME: 1⁄2 to 1 cc anesthetic, 1⁄2 mL K40, or both.

NOTE: Identify and mark the course of the temporalartery and then lightly advance the needle intojoint. If arterial blood enters the syringe, exit theskin, hold pressure for 5 minutes, and reenter eitherslightly anterior or posterior to the artery.

FIGURE 1–18. Local anesthetic block to distinguish TMJ in-volvement from primary involvement of the ear or parotid gland.

NECK 13

THORACIC OUTLET SYNDROME The diagnosis of thoracicoutlet syndrome should be considered in patients presenting withparesthesias in the upper extremity that are not arising from apathologic process in the neck (normal neck examination and radi-ographs) or from a peripheral compression neuropathy. Cervical

ribs, hypertrophy of the scalenus anticus or pectoralis minor mus-cles, Pancoast’s tumor of the chest, or brachial plexopathy causeparesthesias and variable degrees of muscular impairment of theupper extremity. In most cases the lower trunk of the brachialplexus is most vulnerable (ulnar or C8 radicular patterns).

ADSON MANEUVER

SUMMARY: After leaving the cervical spine, theroots form the brachial plexus, which traverses thebase of the neck, through the muscles of the ante-rior cervical triangles, under the clavicle, andthrough the axilla. Compression or traction of theplexus anywhere along this path can lead to neuro-logic impairment of the upper extremity.

MANEUVER: The head and neck are positioned inextension and ipsilateral rotation. The patient isasked to shrug the shoulder and take a deepbreath. The examiner palpates the radial pulse andnotes any decrease when performing the maneuver.In addition, the patient is asked whether this posi-tion reproduces the pain down the arm.

ADDITIONAL SIGNS: A full neurologic examinationof the upper extremity is necessary. Symptoms canalso be brought out by an exaggerated militaryposture (shoulders held back).

INTERPRETATION: A decrease in the radial pulseand a reproduction of the C8 radiculopathy sug-gests thoracic outlet syndrome that must be con-firmed by NCV EMG.

FIGURE 1–19. Adson maneuver to screen for thoracic outletsyndrome.

EMG OF THE UPPER EXTREMITY

SUMMARY: Patients presenting with ulnar or C8root distribution paresthesias, motor loss, or bothbut an absence of signs suggesting a neck or pe-ripheral compression neuropathy should undergoEMG to evaluate for thoracic outlet.

FIGURE 1–20. EMG of the upper extremity to confirm tho-racic outlet syndrome.

1–1 DETAILED EXAMINATION SUMMARY

EXAMINATION MANEUVERS DIAGNOSIS CONFIRMATION PROCEDURESTrapezial or paracervical muscle local 1. Cervical strain Pain with passive neck rotation, local anesthetic placed in the

tenderness and spasm affected muscle (optional)

Painful or limited rotation and lateral bending

Trapezial or paracervical muscle stiffness 2. Osteoarthritis Cervical series x-ray (the lateral view can be used for screening)

Fixed loss of rotation and lateral bending with stiff endpoints

Loss of conjugate movement of the eyes and head

Dorsokyphotic posture

Head and neck locked in the lateral bent position Torticollis Cervical series x-ray (the posteroanterior view can be used for screening)

Local tenderness and spasm in the trapezium muscle

� Spurling sign Cervical radiculopathy Cervical series, MRI, or EMG

Improvement with manual traction

Paraspinal or spinous process tenderness

Abnormal UE neurologic exam; abnormal threshold of reflexes; weakness of grip, biceps, or triceps

Tenderness at the base of the skull 1 inch from Greater occipital neuralgia Local anesthetic placed over the outer fascia of the paraspinalthe midline muscle

Paraspinal or trapezial muscle tenderness and spasm

Abnormal sensory testing over the scalp

TMJ local tenderness TMJ syndrome Local anesthetic placed in the synovial cavity

Restricted opening of the mouth

Clicking or crepitation

Pterygoid muscle spasm

Signs of anxiety or stress

Signs of abnormal teeth wear

Rigidity of the trapezial or paraspinal muscles Suspect vertebral fracture Cross-table lateral x-ray, cervical series x-ray, or MRIor dislocation

Apprehension with any attempts at passive movement

Spinous process tenderness

Positive Adson maneuver Thoracic outlet syndrome Confirmation with EMG

Symptoms reproduced by exaggerated military posture

Abnormalities on neurologic testing of the upper extremity


NECK 15

SENSORY TESTING

SUMMARY: Sensory testing is used to determine theintegrity of the sensory nerve pathways from spinalcord via the spinal nerves to the peripheral skele-ton. A normal sensory exam indicates an intact ner-vous system.

MANEUVER: Light touch or pain sensation is testedin all four extremities (at the fingertips and the tipsof the toes).

INTERPRETATION: Loss of sensation in all four ex-tremities indicates midneck spinal cord injury. Lossof sensation in the legs indicates lower neck spinalcord injury.

FIGURE 1–21. Sensory testing to assess the integrity of thecervical spine.

Examination of the trauma patient focuses on the integrity of the vertebral column.1. Evaluate the patient’s mental status.2. Assess the patient’s airway and cardiovascular stability.3. Check sensation of the four extremities.4. Check motor strength in the hands and feet.5. Obtain a cross-table lateral x-ray of the cervical and fur-

ther radiographic studies if there is any sign of fractureor potential dislocation.

6. If cervical alignment is preserved and there is no obvi-ous fracture, palpate the spinous process for tendernessand alignment (normal cervical lordosis).

EVALUATION OF HEAD AND NECK TRAUMA PATIENTS

7. Obtain an MRI of the cervical spine if focal tendernessis present at any spinous process.

8. Assess range of motion of the neck and palpate theparaspinal muscles.

9. If the patient has extreme muscle guarding, remainsapprehensive with any movement of the neck, and hasfocal tenderness, obtain a neurosurgical consultationto observe for possible occult fracture of the cervicalspine, despite “normal” radiographic studies.

FOR THE TRAUMA PATIENT

SUMMARY

The guidelines for the emergency room evaluation of thehead and neck trauma patient must be strictly adhered to. A step-by-step method to ensure the integrity of the spinalcolumn, spinal nerves, and spinal cord must be followeduntil the provider is assured that the patient’s neurologicalstatus is not in jeopardy.

BOX 1-2


MOTOR TESTING

OBJECTIVE: To determine the integrity of the motornerve pathways from the spinal cord via the spinalnerves to the peripheral motor nerves.

MANEUVER: Grip strength and the strength of dorsi-flexion and plantarflexion are tested on the rightand left sides of the body.

ANATOMY: Normal strength testing in all four extremities indicates an intact nervous system.

INTERPRETATION: Loss of strength in all four extrem-ities indicates midneck spinal cord injury. Loss ofstrength in the legs indicates lower neck spinal cordinjury.

FIGURE 1–22. Motor testing to assess the integrity of the cervi-cal spine.

PALPATION

OBJECTIVE: Palpation of each of the seven spinousprocesses is used to determine the degree of ten-derness of the vertebral bodies and assess theiralignment. The seven spinous processes form asmooth lordotic curve (similar to the lower back).The seventh spinous process at the base is the mostprominent.

MANEUVER: Each spinous process must be pal-pated, lightly at first, to assess alignment, followed by a greater degree of pressure to assess local tenderness.

INTERPRETATION: Any degree of focal spinousprocess tenderness is significant. Involvement of the underlying bone is assumed until proven other-wise. The differential diagnosis includes vertebralcolumn injury, bony tumor, spondylolisthesis, andosteomyelitis.

FIGURE 1–23. Palpation of the spinous processes of the verte-bral bodies.

NECK 17

PALPATION

SUMMARY: The paraspinal muscles and the superiorportion of the trapezial muscle react with severespasm when the spinal column has been traumatized.

MANEUVER: Palpate the paraspinal muscles andthe superior trapezial muscle along the entire lengthof the cervical spine. Compare the muscle tender-ness and degree of muscle spasm on either side ofthe spine.

INTERPRETATION: The most severe reactive cervical muscular strain occurs when the neck hasbeen traumatized. Muscle spasms are extreme withfracture, fracture with dislocation, occult fracture, and malignancy-associated fracture.

FIGURE 1–25. Palpation of the paraspinal muscles in reactivecervical strain.

CROSS-TABLE LATERAL X-RAY

CASE: This 19-year-old hockey player was hardchecked into the rink wall. He suffered a mild con-cussion and severe neck pain. He was transferredto the emergency room in a hard collar. His mentalstatus, cardiovascular exam, airway, and screeningneurologic exam were normal. This cross-table lat-eral x-ray was obtained while the patient was stillin the hard cervical collar.

DIAGNOSIS: Severe reactive cervical strain withstraightening of the cervical lordotic curve. No evidence of fracture or dislocation.

DISCUSSION: Further examination of the patient af-ter the collar was removed showed intense musclespasm, focal tenderness at C4, and great appre-hension with any attempt to rotate the neck. InitialMRI to define an occult fracture was negative.Follow-up MRI at 10 days showed a healing frac-ture of the lamina of C4. The suspicion for fractureremained high because of the focal vertebral spin-ous process tenderness and the severe reactive cervical muscle spasm.

FIGURE 1–24. Cross-table lateral x-ray to assess the align-ment of the cervical spine.


• Loss of rotation can be considered the universal signof the conditions that are intrinsic to the neck.Rotation is impaired in the early stages of nearly allconditions that affect the neck; for this reason, it is thebest maneuver to use to screen for neck conditions(i.e., more sensitive than changes in flexion, lateralbending, and extension).

• Acute muscular spasm associated with acute cervicalstrain causes a loss of full rotation.

• Loss of rotation is the hallmark of osteoarthritis of theneck and correlates directly with its severity.

• Trapezius muscle irritation and spasm is a commonpresenting sign of conditions that are intrinsic to theneck, second only to the changes in the normal rangeof motion of the neck. Of the three divisions of thetrapezius muscle (superior, middle, and lower), selec-tive tenderness, spasm, and irritability of the superiorportion correlate highly with an intrinsic neck process.By contrast, involvement of all three divisions withtenderness, spasm, and irritability is seen with fi-bromyalgia, scoliosis, and poor posture.

• Cervical radiculopathy is classified according to the de-gree of nerve impairment as sensory, sensorimotor, orsensorimotor with spinal cord compression; 80% to85% of patients have sensory impairment only. Theprognosis in these cases is uniformly good; treatmentconsists of rest, stress reduction, attention to posture, amuscle relaxer taken at night, and gentle stretching ex-ercises in rotation over a period of 4 to 6 weeks.

• The prognosis of patients with radiculopathy involvingboth sensory and motor nerves is less predictable.Patients with motor involvement are more likely tohave larger disk herniations, are at higher risk for nervedamage, and are more likely to need neurosurgical in-tervention. For these reasons, subtle motor involve-ment should be sought through examination for vari-ability in the thresholds of the neuroreflexes, muscularfatigue when individual muscles are repeated tested forstrength, and the loss of bulk in the arms and forearms.

• Although the routine cervical series of x-rays consistsof five views, including the odontoid, lateral, pos-teroanterior, and two oblique views, the lateral viewprovides the most useful clinical information. It can be

CLINICAL PEARLS

used to screen for loss of alignment (e.g., cervicalstrain, whiplash), the degree of osteoarthritis (at thefacet and paravertebral joints), disk space narrowing(osteoarthritis or radiculopathy), or bony disorders(compression fracture).

• All patients who present with symptoms and signs ofradiculopathy should undergo a cervical series ofradiographs. Foraminal encroachment is the underly-ing cause of cervical radiculopathy in 90% of cases. Ifthe oblique views of the neck do not disclose at least50% narrowing of the foramina at the appropriatespinal level, MRI should be performed to evaluate forherniated disk.

• Every patient who has sustained severe trauma to thehead or neck must be cleared neurologically beforeproceeding to special radiographic studies. The firstpriority is to perform a screening neurologic exam.Next, a cross-table lateral x-ray is obtained to assess thealignment of the vertebral bodies (with the patient inthe transport collar). Next, the collar is removed, thespinous processes are palpated, and the neck musclesare assessed for irritability. Once the patient is clearedneurologically, special studies are obtained to furtherdetermine alignment and evaluate for fracture, disloca-tion, or epidural bleeding.

• Caution: Injury to the vertebral column must be as-sumed if the patient manifests anxiety when one at-tempts to remove the transport collar, guarding whenone attempts to move the neck in any direction, orrigidity of the paraspinal muscles. For instance, thebody interprets even a small, nondisplaced vertebralbody or laminar fracture as a potential threat to thespinal cord and nerves. This threat generates severe re-active muscle spasm.

• For major trauma with signs of neurologic compro-mise, consult the neurosurgeon.

• For major trauma without signs of neurologic compro-mise, proceed cautiously to radiographic studies to ex-clude occult neck fracture and epidural bleeding.

• Rotating the neck is nearly impossible in patients whohave sustained significant neck trauma. Vertebral bodysubluxation or fracture leads to neck rigidity from in-tense muscle spasm.

19

CHAPTER 2: SHOULDER


Diagnoses

Rotator cuff syndromes (most common)Impingement syndromeRotator cuff tendonitisRotator cuff tendon thinning

Rotator cuff tendon tearFrozen shoulder

Acromioclavicular (AC) jointOsteoarthritisAC separationOsteolysis of the clavicle

Subscapular bursitis

Sternoclavicular jointStrain or inflammatory arthritisSeptic arthritis (intravenous drug abuse)

Glenohumeral jointOsteoarthritisInflammatory arthritisSeptic arthritis

Multidirectional instability of the shoulderDislocationSubluxationGlenoid labral tear

Referred painCervical spineLungDiaphragmUpper abdomen .

Confirmations

Examination, passive painful arcLidocaine injection testX-ray: shoulder series showing a narrow subacromial

spaceMagnetic resonance imaging (MRI) arthrographyExamination showing a loss of range of motion,

normal x-ray

X-ray: shoulder seriesX-ray: weighted views of the shoulderX-ray: shoulder series


Local anesthetic blockAspiration and culture

X-ray: shoulder series (axillary view)Synovial fluid analysisSynovial fluid culture

X-ray: shoulder seriesAbnormal sulcus signDouble contrast arthrography

Neck rotation, x-ray, MRIChest x-rayChest x-ray, computed tomography scanChemistries, ultrasound


INTRODUCTION The unique anatomy of the shoulderallows the greatest range of motion of all of the joints of thebody, but at a tremendous price: The vital rotator cuff ten-dons that are responsible for the support and movement ofthe shoulder joint are susceptible to the compression forcesbetween the undersurface of the acromion and the top ofthe humeral head. Specifically, the supraspinatus and infra-spinatus tendons are the only tendons in the body that mustperform their vital functions while being subjected to thecompressive forces between these two bony surfaces. Everytime the arm is raised to shoulder level or above, these ten-dons are compressed and are subject to friction in this sub-acromial space, a force called subacromial impingement.The largest lubricating sac in the body, the subacromialbursa, attempts to counter these forces but often fails tokeep up with the demands; subacromial bursitis results. Ifthe subacromial bursa does not effectively counter the fric-tion and compression caused by overhead reaching, inflam-mation is carried over to the tendons, and rotator cuff ten-donitis results. Inflammation of the supraspinatus andinfraspinatus tendons is the most common condition af-fecting the shoulder, a problem that affects nearly everyoneat least once in their lifetime.

Left unrecognized and untreated, subacromial impinge-ment can persist and progress over months and years. Therepeated mechanical irritation of impingement and the re-lentless deleterious effects of inflammation lead to recur-rent and chronic subacromial bursitis and rotator cufftendonitis. This in turn can lead to degenerative thinningof the tendon and ultimately to rotator cuff tendon tearwith accompanying muscle atrophy. When approachingthe patient presenting with upper arm pain and shoulderdysfunction, the provider must view the conditions thataffect the subacromial area and rotator cuff tendons, inparticular, as a continuum of pathological states: from theearliest stage of mechanical impingement through activesubacromial bursitis and uncomplicated rotator cuff ten-donitis to the degenerative rotator cuff tendon thinningand the final result of rotator cuff tendon tear. The chal-lenge to the provider is to determine where on this con-tinuum the patient falls.

Frozen shoulder, the reversible loss of glenohumeralrange of motion, is another complication of impingementand rotator cuff tendonitis. At least 10% of patients with active rotator cuff tendonitis develop frozen shoulder oradhesive capsulitis. Although rotator cuff tendonitis is itsmost common cause, frozen shoulder can also result fromstroke, shoulder surgery, or bony fracture.

The second most common condition affecting the shoul-der involves the acromioclavicular (AC) joint. The claviclejuts out from the bony thorax and abuts the acromialprocess of the scapula. The joint is susceptible to wear-and-tear and injury with repetitive overhead reaching, to-and-fromovement across the chest, and compression from lateralshoulder pressure. Degenerative osteoarthritis of the ACjoint is nearly universal, although not every patient devel-ops symptoms. AC separation is another common condi-tion that occurs after direct blows to the shoulder or falls onan outstretched arm.

Glenohumeral osteoarthritis is surprisingly uncommongiven the wide range of motion the shoulder is capable of.Unlike degenerative osteoarthritis of the AC joint, osteo-

arthritis is rare outside the setting of previous bony fracture,dislocation, or complete rotator cuff tendon tear. Hyper-mobility or multidirectional instability of the glenohumeraljoint is also associated with late-onset osteoarthritic change,probably through the complication of glenoid labral tear.

The other major bursa affecting the shoulder is the sub-scapular bursa. Subscapular bursitis, also called costotho-racic syndrome, is caused by the exaggerated movement ofthe scapula across the bony rib cage when normal gleno-humeral movement is impaired (frozen shoulder andglenohumeral joint arthritis). This exaggerated degree ofshoulder shrugging increases friction between the secondand third ribs and the undersurface of the superior medialangle of the scapula.

The shoulder is susceptible to trauma, including fracturesof the clavicle in early life and humeral head and neck frac-tures in older adults with advanced osteoporosis.

Finally, pain is commonly referred to and through theshoulder from conditions arising in the neck and condi-tions affecting the heart, lungs, pleura, great vessels, or up-per abdomen.

SYMPTOMS Conditions intrinsic to the shoulder causethe following symptoms: shoulder pain provoked by spe-cific shoulder movements, loss of mobility (impaired reach-ing, lifting, pushing, and pulling, pain or stiffness), bony orsoft tissue deformity (AC separation and arthritis, disloca-tion), muscular weakness, or a combination of these symp-toms. However, the strongest clue to a specific anatomic diagnosis often is based on the patient’s description and lo-cation of their pain.

Shoulder pain aggravated by reaching and localized tothe lateral deltoid area is the most common pain pattern.This is the classic pain pattern of impingement syndromeand the various stages of rotator cuff tendonitis: simplestrain, uncomplicated tendonitis, chronic calcific ten-donitis, and tendonitis complicated by tendon tear. Whenthis pain pattern is accompanied by joint stiffness and ameasurable loss of movement in external rotation or ab-duction, frozen shoulder is the most likely diagnosis.When this pain pattern is complicated by weakness and ameasurable loss of strength in external rotation or abduc-tion (a loss that cannot be attributed to pain and poor ef-fort), rotator cuff tendonitis complicated by tendon tear ismost likely.

Shoulder pain localized to the anterior shoulder area isless common and is most characteristic of the conditions af-fecting the AC joint, glenohumeral joint, or the anteriortendons (long head of the biceps, subscapularis, and rarelythe pectoralis major tendon). When this pain is well local-ized and specifically identified by the patient (often point-ing to the distal end of the clavicle), AC separation or os-teoarthritis of the AC joint is the most likely diagnosis.When this pain is aggravated by movement of the shoulderin several different directions, involvement of the gleno-humeral joint should be suspected. When this pain is ag-gravated by selective movement in one direction, tendonitisof one of the anterior tendons should be suspected (lifting,the long head of the biceps; reaching, rotator cuff ten-donitis, especially when the subscapularis predominates;pushing, pectoralis major).

SHOULDER 21

Posterior shoulder pain is the least common pain patternat the shoulder. Rotator cuff tendonitis can refer pain overthe broad area of the scapula, the anatomic location of therotator cuff muscles. However, when the pain localizes tothe superior medial angle of the scapula, subscapular bursi-tis is the more likely diagnosis. Poorly localized posteriorshoulder pain is referred from the neck, is caused by com-pression neuropathy, or arises from the underlying bonystructures. Poorly localized and vaguely described poste-rior shoulder pain may also reflect exaggerated symptomsin patients who are malingering or are involved in worker’scompensation claims or insurance litigation.

ness of the subacromial space. Next, the painful arc maneu-ver (passively abducting the glenohumeral joint while si-multaneously preventing shoulder shrugging) is combinedwith the degree of subacromial tenderness to assess the de-gree of subacromial impingement. If impingement is con-firmed, isometric testing of each individual tendon is per-formed to determine the number of inflamed tendons; forexample, subacromial tenderness combined with isometri-cally resisted external rotation identifies the involvement ofthe infraspinatus tendon. Pain reproduced by isometricallyresisted abduction identifies the involvement of thesupraspinatus tendon. Pain reproduced by resisted flexionof the elbow identifies the involvement of the long head ofthe biceps. To complete the shoulder exam, focal tendernessof the AC joint, sternoclavicular (SC) joint, and subscapu-lar bursa is determined by direct palpation.

Lateral deltoid pain Impingement syndromeSubacromial bursitisRotator cuff tendonitisRotator cuff tendon tearDeltoid tendonitis

Anterior shoulder pain Acromioclavicular osteoarthritis

Acromioclavicular separation

Osteolysis of the clavicleFrozen shoulderGlenohumeral osteoarthritisGlenohumeral

inflammatory arthritisGlenohumeral septic

arthritisMultidirectional instabilitySternoclavicular strainSubscapularis tendonitis

Posterior shoulder pain Subscapular bursitisReferred pain Cervical strain

Cervical radiculopathyMedical causes of

shoulder pain

DIFFERENTIAL DIAGNOSIS OF SHOULDERPAIN BASED ON ANATOMIC AREA

EXAMINATION The examination of the shoulder al-ways begins with assessment of the overall function of theglenohumeral joint followed by a focused evaluation of themost common conditions affecting the surrounding ten-dons and joints. Functional testing determines the involve-ment of the glenohumeral joint, readily assesses the severityof the condition, and includes the following maneuvers:range of motion testing in abduction and external rotation(passively performed), estimation of the strength of the in-fraspinatus muscle (the muscle that is most susceptible to at-rophy with disuse), and an assessment of the overall tight-

1. Evaluate the general function of the shoulder andglenohumeral joint: Observe the general movementof the shoulder, estimate the tone and strength ofthe supporting muscles, especially the infraspinatus,and determine the overall tightness of the subacro-mial space.

2. Perform the painful arc maneuver to determine thedegree of subacromial impingement.

3. Palpate the subacromial space, the bicipital groove,and the anterior glenohumeral joint line.

4. Perform isometric testing of the major supportingtendons rotator cuff and biceps.

5. Palpate the AC joint, the SC joint, and the sub-scapular bursa for tenderness.

6. Perform range of motion of the neck or a generalmedical exam if a referred source of shoulder pain issuspected.

ESSENTIAL EXAMINATION OF THE SHOULDER

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL SHOULDER FUNCTIONAND DIFFERENTIAL DIAGNOSIS

The next 10 maneuvers represent the minimal examinationof the patient presenting with shoulder symptoms. Functiontesting, range of motion measurement, and screening ma-neuvers for tendonitis, the accessory joints, and bursitis pro-vide enough information to triage to x-ray, order appropri-ate labs, suggest general treatment recommendations, orproceed to more detailed examination and treatment.

BOX 2-1

BOX 2-2


THE TOUCHDOWN SIGN

SUMMARY: Full abduction requires a normal gleno-humeral joint, intact rotator cuff tendons, a freelymoving AC joint, and well-developed deltoid androtator cuff muscles. This is the optimal screeningmaneuver for intact abduction.

MANEUVER: The patient is asked to raise both armsdirectly overhead. The smoothness of the move-ment, the degree of discomfort, and the ability tocomplete the maneuver are compared side to side.Similarly, the ability to smoothly control loweringthe arm is compared side to side (the latter maneu-ver is analogous to the drop-arm sign).

INTERPRETATION: Severe pain limits abduction withacute rotator cuff tendonitis, rotator cuff tendonitiswith partial tear, the uncommon inflammatory or sep-tic arthritis of the glenohumeral joint, and advancedglenohumeral arthritis. Patients with dislocation orfracture will not attempt the maneuver. Patients withmild glenohumeral osteoarthritis or frozen shoulderhave restricted movement with modest pain. Patientswith complete rotator cuff tendon tears have impairedmovement caused by profound weakness. A diagno-sis of polymyalgia rheumatica should be consideredin older adults who complain of bilateral stiff shoul-ders (with or without concurrent hip involvement).

FIGURE 2–1. The touchdown sign is used to assess activeglenohumeral joint abduction.

THE APLEY SCRATCH SIGN

SUMMARY: Full rotation requires a normal gleno-humeral joint, intact rotator cuff tendons, and rea-sonably well-developed rotator cuff muscles. TheApley scratch maneuver is the most practical meansof screening shoulder movement. In addition, it pro-vides the most objective measurement of rotation.

MANEUVER: The patient is asked to scratch thelower back and place the thumb as high up on theback in the midline as comfortable. The distancebetween the thumbs is measured, and the levelreached by the thumb is recorded.

INTERPRETATION: Rotation is limited with frozenshoulder, arthritis of the glenohumeral joint (os-teoarthritis or inflammatory arthritis), and the acute inflammation of rotator cuff tendonitis. The loss ofrotation correlates well with the severity of theseconditions. Rotation of the shoulder is impossible or the patient refuses to perform the maneuver withdislocation and humeral head fracture.

FIGURE 2–2. The Apley scratch sign is used to screen rota-tion of the glenohumeral joint.

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ISOMETRIC TESTING

SUMMARY: The infraspinatus and teres minor muscles are responsible for external rotation of theshoulder. This is the first muscle to atrophy withany chronic condition affecting the shoulder. It isalso the second most common rotator tendon torupture. In general, testing the strength of externalrotation provides the best screening of the shoul-der’s overall conditioning.

MANEUVER: Using a Theraband, bungee cord, or10-10 resistance bands (depicted here), the patient is asked to pull the bands apart while keeping theelbows at the sides (pure rotation). The symmetry of motion, strength, and ability to hold the bandssteady are compared side to side.

INTERPRETATION: Unilateral weakness of externalrotation is seen with rotator cuff tendon tear, C5radiculopathy, and the uncommon suprascapularnerve palsy (hod carrier’s disease). Bilateral weak-ness of external rotation is seen with poor musculardevelopment, bilateral rotator cuff tears, bilateralglenohumeral arthritis, or any chronic disease.

FIGURE 2–3. Isometric testing of the external rotationusing resistance bands.

THE WEIGHTED TOUCHDOWN SIGN

SUMMARY: Full abduction requires a normal gleno-humeral joint, intact rotator cuff tendons, a func-tional AC joint, and well-developed deltoid and rotator cuff muscles. The ability to lift progressivelyheavier weights provides an objective measurementof general, overall shoulder strength.

MANEUVER: The patient is asked to raise 1-, 2-,and 5-lb weights overhead. The smoothness of themovement, the degree of discomfort, and the abilityto complete the maneuver are compared side toside.

INTERPRETATION: Inability to lift the unweightedarm is seen with a complete rotator cuff tear, severemuscular atrophy, severe C5 radiculopathy, or therare suprascapular nerve palsy. Ability to lift 1- or 2-lb weights is compatible with a partial rotator cuff tear, poorly developed muscles, or a partial C5 radiculopathy. The ability to lift 5 lb or more is consistent with intact rotator cuff tendon.

FIGURE 2–4. The weighted touchdown sign to assess over-all shoulder strength.


THE SULCUS SIGN

SUMMARY: The deltoid muscle arises from theacromion and attaches to the midhumerus. Thesupraspinatus tendon attaches to the greater tuber-cle. Downward movement of the humeral head isrestricted by the tone and bulk of the deltoid, thetone and thickness of the supraspinatus tendon, andthe redundancy of the glenohumeral capsule. Thismaneuver is used to assess the looseness of theshoulder joint, the subacromial space (subluxation),and the patient’s potential tolerance of the pendu-lum stretch exercise.

MANEUVER: The patient is asked to relax the shoul-der. One hand is placed atop the acromion, andone hand is placed in the antecubital fossa. Down-ward pressure is applied to the arm to open thesubacromial space. The examiner assesses thelooseness of the shoulder and the discomfort of the maneuver.

INTERPRETATION: A tight shoulder—no movementwith downward pressure—is seen with extreme guarding and tension due to pain, frozen shoulder, fibromyalgia, or an overly developed deltoid.Downward movement of 1⁄4 inch is considered aver-age looseness. Downward movement of more than 1⁄2 inch indicates hypermobility (subluxation).

FIGURE 2–5. The sulcus sign evaluates the looseness or tight-ness of the shoulder and can be used to determine the appropri-ateness of the pendulum stretch exercise.

PASSIVE PAINFUL ARC MANEUVER

SUMMARY: Several maneuvers are used to definethe degree of subacromial impingement, includingthe Neer and Hawkins maneuvers. The passivelyperformed painful arc maneuver (depicted here) isthe easiest maneuver to perform and provides themost reproducible assessment of impingement. Thecombination of this maneuver with focal tendernessdefines the degree of subacromial impingement.

MANEUVER: One hand is placed atop theacromion, and one hand grasps the proximal fore-arm. The patient is asked to relax the shoulder.While applying simultaneously downward pressureon the acromion to prevent the protective effect ofshrugging, the arm is carefully raised, and the an-gle at which pain is reproduced is noted.

INTERPRETATION: Mild impingement is defined by pain reproduced at 90 degrees of abduction.Moderate impingement occurs at an angle of 60 to70 degrees, and severe impingement is defined bypain at 45 degrees.FIGURE 2–6. Subacromial impingement is assessed by the pas-

sive painful arc maneuver.

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PALPATION OF THE SUBACROMIAL SPACE

SUMMARY: The subacromial space is occupied bythe subacromial bursa, the rotator cuff tendons, and 1 to 2 mm of articular cartilage. The deltoid muscle is layered over the acromion, the subacromialspace, and the greater tubercle of the upperhumerus. Subacromial tenderness, just under the lateral edge of the acromion, combined with thepassive painful arc maneuver defines the impinge-ment syndrome.

MANEUVER: The anterior, lateral, and posterioredges of the acromion are marked with a pen. Thesubacromial space is palpated just under the lateraledge of the acromion.

INTERPRETATION: Focal tenderness is typical of im-pingement syndrome, active rotator cuff tendonitis,rotator cuff tendonitis with tear, and bony lesions ofthe humerus. Diffuse tenderness is characteristic ofacute subacromial bursitis and patients with activeshoulder tendonitis with a low pain threshold.

FIGURE 2–7. Palpation of the subacromial space.

PALPATION OF THE AC JOINT

OBJECTIVE: The AC joint is formed by the acromialprocess of the scapula and the distal end of theclavicle. The joint is held together by the acromio-clavicular, coracoacromial, and coracoclavicularligaments. The joint is susceptible to osteoarthritisand traumatic separation.

MANEUVER: The anterior, lateral, and posterioredges of the acromion are marked with a pen. The AC joint is 13⁄4 inches from the lateral edge of the acromion.

INTERPRETATION: Osteoarthritis of the AC joint is characterized by bony enlargement. An os-teoarthritic flare is characterized by bony enlarge-ment combined with local tenderness. Local tender-ness with normal-positioned and normal-sizedbones is characteristic of a first-degree AC separa-tion. Local tenderness and bony deformity aftertrauma to the shoulder are seen with second- andthird-degree AC separations.

FIGURE 2–8. Palpation of the AC joint.


PALPATION OF THE SUBSCAPULAR BURSA

SUMMARY: The levator scapula attaches to the su-perior medial angle of the scapula. The rhomboidmuscles attach to the medial border of the scapula.The middle portion of the trapezius muscle formsthe outer muscular layer that covers the musclesand the scapula. The subscapular muscle is locatedunderneath the scapula, acting as a natural protec-tive pad between the ribs and scapula.

MANEUVER: The ipsilateral arm is fully abducted.The patient is asked to place the hand on the con-tralateral shoulder. The superior medial angle of thescapula and the center of the ribs are marked with a pen. Bursal tenderness is palpated directly over the rib closest to the angle of the scapula.

INTERPRETATION: A half dollar–sized area of ten-derness at the superior medial angle is most com-monly caused by subscapular bursitis as opposed to the generalized muscular tenderness of the strain of the upper back muscles. Primary involvement of the rib or the scapula must be considered in the case of the patient with a known primary cancer (e.g., breast, lung, prostate).

FIGURE 2–9. Palpation of the subscapular bursa.

PALPATION OF THE SC JOINT

SUMMARY: The SC joint is formed by the upper portion of the sternum and the proximal clavicle.When the joint swells, the proximal clavicle pro-jects anteriorly. The anterior position of the claviclecauses a pseudoenlargement of the clavicle.

MANEUVER: The sternal notch, proximal clavicle,and center of sternum are palpated and markedwith a pen. The SC joint is palpated at the junctionof the sternum and the proximal clavicle, approxi-mately 3⁄4 to 1 inch from the midline.

INTERPRETATION: SC joint involvement is uncom-mon. SC joint strain is characterized solely by localtenderness. SC joint local tenderness and pseudo-enlargement of the clavicle are seen with SC joint arthritis, most commonly Reiter’s disease. A red,hot, swollen joint is a unique complication of intra-venous drug abuse, acute septic arthritis.FIGURE 2–10. Palpation of the SC joint.

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TRIAGE TO X-RAY The patient has a history of trauma,is at risk of bony injury, has recurrent episodes of rotatorcuff tendonitis, has significant loss of range of motion in ro-tation or abduction, or has an enlarged AC or SC joint byhistory or exam:

• Order three views of the shoulder for patients with a historyof fall to an outstretched arm, a severe blow to the shoul-der, or a hyperextension injury (humeral or clavicular frac-ture, AC separation, or glenohumeral joint dislocation).

• Order three views of the shoulder for patient with recur-rent or chronic rotator cuff tendonitis (narrowing of thesubacromial space also known as high-riding humeralhead seen with thinning of the rotator cuff tendons).

• Order weighted views of the shoulder (traumatic AC separation).

• Order three views of the shoulder and an axillary view(glenohumeral joint osteoarthritis or as a part of theworkup for frozen shoulder).

• Order apical lordotic views of the upper chest (SC jointswelling and subluxation).

TRIAGE TO THE LAB For patients suspected of havinggout, acute arthritis, or septic arthritis (rare):• Order a complete blood cell count, uric acid, and eryth-

rocyte sedimentation rate for patients with acute pain, ex-quisite anterior joint line tenderness, signs of active in-flammation, and dramatic loss of range of motion in alldirections (gout or acute arthritis) and include blood cul-tures if the acute inflammatory changes are accompaniedby significant fever or concurrent signs of infection else-where in the body.

CONSIDER A BONE SCAN For patients with vaguepain about the shoulder with a history of previous solid tu-mor and for patients with osteoporosis, a history of fall, anda high suspicion for occult fracture.

CONSIDER MRI For patients with an examination sug-gestive of rotator cuff tear or glenoid labral tear from previ-ous subluxation or dislocation.

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate shoulder pain and stiffness,unrestricted movement of the joint, and normal strength inrotation and abduction.

• Restrict reaching, lifting, pushing, and pulling.• Apply ice up to four times a day or take a full-strength

nonsteroidal anti-inflammatory drug for 10 to 14 days.• Perform the pendulum stretch exercise once or twice

daily.• Perform isometric toning exercise of external rotation.

DETAILED EXAMINATION: SPECIFIC SHOULDERDIAGNOSES

Perform a detailed examination of the shoulder if the pa-tient has persistent or chronic symptoms, has sustained aninjury, demonstrates moderate loss of range of motion, orhas lost strength in rotation or abduction.


IMPINGEMENT SYNDROME Shoulder pain and impairedreaching at or above shoulder level that is caused by the directbony contact of the undersurface of the acromion and the greatertubercle of the humeral head is called impingement syndrome.

PASSIVE PAINFUL ARC MANEUVER

SUMMARY: Several maneuvers are used to definethe degree of subacromial impingement, includingthe Neer and Hawkins maneuvers and the pas-sively performed painful arc maneuver (depictedhere). The painful arc maneuver is the easiest toperform and is applicable to most patients with clinically significant impingement. The combinationof this maneuver with focal tenderness defines thedegree of subacromial impingement.

MANEUVER: One hand is placed atop theacromion, and one hand grasps the proximal fore-arm. The patient is asked to relax the shoulder.While downward pressure is applied on theacromion to prevent the protective effect of shrug-ging, the arm is carefully raised, and the angle atwhich pain is reproduced is noted.

INTERPRETATION: Mild impingement is defined by pain reproduced at 90 degrees of abduction.Moderate impingement occurs at an angle of 60 to70 degrees, and severe impingement is defined bypain at 45 degrees.

FIGURE 2–11. Subacromial impingement assessed by the pas-sive painful arc maneuver.

LIDOCAINE INJECTION TEST

SUMMARY: The lidocaine injection test is used toconfirm impingement as the primary cause of shoul-der pain and to define the various presentations ofshoulder tendonitis (rotator cuff tendonitis, rotatorcuff tendonitis with tear, and rotator cuff tendonitiscomplicated by frozen shoulder) and glenohumeraljoint arthritis.

POSITIONING: Sitting, relaxed shoulder, with orwithout downward traction applied to the elbow.

SURFACE ANATOMY: Lateral edge of the acromion.

POINT OF ENTRY: 1 to 11⁄2 inches below the mid-point of the acromion.

ANGLE OF ENTRY: Paralleling the acromion.



ANESTHESIA: Ethyl chloride, skin: 1 mL, deltoid; 1 to 2 mL, subacromial bursa.

FIGURE 2–12. The lidocaine injection test is used to confirmimpingement.

It is the mechanical abnormality of the shoulder that is the princi-ple cause of inflammation of the subacromial bursa—commonshoulder bursitis—and rotator cuff tendonitis.

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ROTATOR CUFF TENDONITIS Rotator cuff tendonitis, in-flammation of the important supporting tendons of glenohumeraljoint, results from repeated subacromial impingement and a fail-ure of the subacromial bursa to provide adequate lubrication

ISOMETRIC TESTING

SUMMARY: Of the three abductors of the shoulder—the deltoid, supraspinatus, and trapezius—thesupraspinatus is responsible for abduction in the mi-darc. Active shoulder tendonitis is defined by repro-ducing the patient’s pain with active isometric test-ing of the actions of the various tendons. Activeresisting abduction in the midarc defines the degreeof inflammation of the supraspinatus tendon.

MANEUVER: The patient’s arm is abducted to 45degrees. The patient is asked to actively abduct thearm against the resistance of the examiner’s handplaced at the elbow. The effort, strength, and dis-comfort are noted.

ADDITIONAL SIGNS: The diagnosis of rotator cufftendonitis is suggested when the signs of impinge-ment (local tenderness and the painful arc maneu-ver) are accompanied by pain reproduced by iso-metric testing of the rotator cuff tendons. Strength ofmidarc abduction should be normal unless the ten-don has been split or torn.

INTERPRETATION: Isometric induced pain and nor-mal strength suggests rotator cuff tendonitis. Painand weakness of midarc abduction suggests rotatorcuff tendonitis with tear. Weakness without painsuggests chronic rotator cuff tear, muscular atrophy,C5 radiculopathy, or suprascapular nerve palsy.

FIGURE 2–13. Isometric testing of the supraspinatus tendonin midarc.

ISOMETRIC TESTING

SUMMARY: The infraspinatus is the primary externalrotator of the shoulder (the teres minor plays a mi-nor role). This maneuver is performed with theshoulder kept in neutral position. If the patient’spain is reproduced only by resistance to externalrotation, one can assume that the infraspinatus ten-don is solely responsible for the active tendonitis.

MANEUVER: The elbow is flexed to 90 degrees andheld next to the body with one hand. The patient isasked to actively rotate the arm against the resis-tance of the examiner’s hand placed at the wrist.The effort, strength, and discomfort are noted.

ASSOCIATED SIGNS: The diagnosis of rotator cufftendonitis is suggested when the signs of impinge-ment (local tenderness and the painful arc maneu-ver) are accompanied by pain reproduced by iso-metric testing of the rotator cuff tendons.

INTERPRETATION: Identical to isometric testing ofthe supraspinatus tendon (see Figure 2–13).

FIGURE 2–14. Isometric testing of the infraspinatus tendon inneutral position.

and protection. Of the four rotator cuff tendons, the supraspinatustendon is the most susceptible to injury and inflammation becauseof its vulnerable position just under the acromion process.


NORMAL SUBACROMIAL WIDTH

SUMMARY: The subacromial space—the anatomicareas between the superior humeral head and theundersurface of the acromion—contains the sub-acromial bursa, the rotator cuff tendons, and 2 mmof articular cartilage. Chronic inflammation of thesubacromial bursa leads to bursa wall fibrosis andeventual loss of its normal lubricating function. If thebursa cannot protect the rotator cuff tendons fromthe friction and compressive forces of subacromialimpingement, the rotator cuff tendons will be vulner-able to mucinoid degenerative thinning.

CASE: This radiograph demonstrates the normal relationships of the acromion and the humeralhead. The normal subacromial space (depictedhere) measures 10 to 11 mm. Narrowing of thespace correlates directly with thinning of the rotatorcuff tendons. Radiologists often refer to a narrowedsubacromial space as a “high-riding humeral head”sign.FIGURE 2–15. X-rays of the shoulder to determine the normal

subacromial width.

ABNORMAL SUBACROMIAL WIDTH

CASE: This patient had a history of recurrent rotatorcuff tendonitis over many years. He worked in con-struction all his life, performing heavy physicalwork, including physical work at or above hisshoulder level. He was forced to retire because ofrefractory right shoulder pain. This radiographdemonstrates a near obliteration of the subacromialspace, measuring 1 mm or less (loss of the subacro-mial bursa and complete thinning of the rotator cufftendons). The greater tubercle of the humeral headshows severe sclerosis caused by the chronic com-pressive forces of impingement over the years.Patients with loss of the normal subacromial spaceare at the highest risk for rotator cuff tendon tear.(Radiologists often fail to comment on the scleroticchanges occuring at the greater tubercle, the radio-graphic signs of impingement.)

FIGURE 2–16. X-rays of the shoulder demonstrating the abnor-mal subacromial width.

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FROZEN SHOULDER Frozen shoulder or adhesive capsulitis,a loss of the normal range of motion of the glenohumeral joint, isa direct result of injury or inflammation of the shoulder. The most common causes are rotator cuff tendonitis, fracture of

LIDOCAINE INJECTION TEST

SUMMARY: Patients presenting with severe shoulderpain and severe guarding on examination need lo-cal anesthetic block in order to more accurately as-sess the function of the shoulder. The lidocaine in-jection test is used to confirm rotator cuff tendonitis,exclude rotator cuff tear (normal strength), excludeglenohumeral joint involvement, and determine thedegree of frozen shoulder (persistent loss of rangeof motion).

POSITIONING: Sitting, relaxed shoulder, downwardtraction applied to the elbow.

SURFACE ANATOMY: Lateral edge of the acromion.

POINT OF ENTRY: 1 to 11⁄2 inches below the mid-point of the acromion.

ANGLE OF ENTRY: Paralleling the acromion.



ANESTHESIA: Ethyl chloride, skin: 1 mL, deltoid; 1 to 2 mL, subacromial bursa.

FIGURE 2–17. The lidocaine injection test confirming rotatorcuff tendonitis.

the humerus, dislocation of the glenohumeral joint, and shouldersurgery. In 95% of cases the contracture of the glenohumeral capsule is reversible.

APLEY SCRATCH SIGN

SUMMARY: Full rotation requires a normal gleno-humeral joint, intact rotator cuff tendons, and rea-sonably well-developed rotator cuff muscles. TheApley scratch sign is the most practical and objec-tive measurement of rotation.

MANEUVER: The patient is asked to scratch thelower back and place the thumb as high up on theback in the midline as comfortable. The distancebetween the thumbs is measured, and the levelreached by the thumb is recorded.

ADDITIONAL SIGNS: The touchdown sign demon-strating an abnormal abduction range of motion is typically abnormal as well. The passive range ofmotion of external rotation and abduction are dra-matically lower than that of any other direction.Signs of active rotator cuff tendonitis often accom-pany the exam because it is the most commoncause of frozen shoulder.

INTERPRETATION: Rotation is limited with frozenshoulder, arthritis of the glenohumeral joint (osteo-arthritis or inflammatory arthritis), and the acute inflammation of rotator cuff tendonitis. The loss ofrotation correlates well with the severity of theseconditions.

FIGURE 2–18. The Apley scratch sign to estimate the sever-ity of frozen shoulder.


ARTHROGRAPHY OF THE GLENOHUMERAL JOINT

SUMMARY: The diagnosis of frozen shoulder isbased on the clinical criteria of preferential loss ofexternal rotation and abduction relative to other di-rections of motion, no underlying primary involve-ment of the glenohumeral joint, and no concomitantneurologic disease that would restrict range of mo-tion. Plain radiographs are necessary to exclude anunderlying glenohumeral osteoarthritis that canmimic the physical findings of frozen shoulder.Arthrography (depicted here to emphasize the lossof distensibility of the glenohumeral joint) is not nec-essary to confirm the diagnosis.

CASE: This middle-aged woman with insulin-dependentdiabetes developed a painful shoulder 6 monthsago. She was treated with restriction in reachingand heavy lifting, ice, ibuprofen, and physical ther-apy exercises. Her pain gradually improved, but she gradually developed stiffness and lost full rangeof motion. Her Apley scratch signs were 10 inchesapart. Her passive measurements of external rotation and abduction were 15 degrees and 50 degrees, respectively. The arthrogram depicted heredemonstrates a poorly filled synovial cavity that ac-cepted only 6 to 7 mL of radiopaque dye.

FIGURE 2–19. Arthrography of the glenohumeral jointdemonstrating loss of the normal synovial cavity distensibility.

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stretched arm or direct blow), age greater than 62 years, a historyof recurrent tendonitis, a narrowed subacromial space on x-ray,muscular weakness, systemic steroids, concomitant rheumatic disease, and intratendinous injection.

HIGH-RIDING HUMERAL HEAD

CASE: This 74-year-old woman has a 25-year his-tory of “shoulder bursitis.” She is unable to raiseher arm overhead, cannot comb her hair, and cannot reach up to remove dishes from her highershelves. She uses her left arm to assist with abduc-tion. Her external rotation strength is nonexistent,and her abduction strength is poor.

DIAGNOSIS: Complete rotator tendon tear.

DISCUSSION: The high-riding humeral head sign focuses on the cephalad migration of the humeralhead. From a clinical perspective, a more helpfuldescription would be “narrowed subacromialspace,” thus shifting the emphasis to the narrowedthickness of the soft tissues located between thehumeral head and the undersurface of theacromion. The normal width is 10 to 11 mm (1 mmhumeral articular cartilage, 7 mm rotator cuff ten-don, 1 mm subacromial bursa).

FIGURE 2–21. The high-riding humeral head sign, strongestevidence of mucinoid degenerative thinning of the rotator cufftendons.

ROTATOR CUFF TENDON TEAR In the majority of casesrupture of the rotator cuff tendons occurs as a complication of pre-existing rotator cuff tendonitis. Other risk factors include chronicmucinoid degenerative tendon thinning, injury (fall to an out-

ROTATOR CUFF TENDON WEAKNESS

SUMMARY: Approximately 15% of cases of rotatorcuff tendonitis are complicated by tear. The hallmarkfeature of rotator cuff tear is loss of strength in thedirection of the affected tendon (external rotation,infraspinatus; midarc abduction, supraspinatus). Thediagnostic challenge is to identify the patient at riskand to evaluate the extent of the tear by estimatingthe degree of weakness and the impact of the tearon overall shoulder function. In many cases, a lido-caine injection test (see Figure 2–17) is necessary toreduce pain to allow completion of the examination.

MANEUVER: To assess the impact of a possible rota-tor cuff tendon tear on overall function, the patient isasked to actively raise the arm overhead. Patientswith large complete tears (depicted here) are unableto raise the arm without contralateral arm assist. Inorder to grade the size of tears and their impact onthe shoulder, the patient can be asked to raise pro-gressively heavier weights (see Figure 2–4).

ASSOCIATED SIGNS: Weakness of external rotation(see Figure 2–3), weakness of midarc abduction(see Figure 2–13), bruising of the anterior shoulderor upper arm, previous ruptured biceps tendons (in-creased risk), and swelling of the glenohumeraljoint (depicted here).

FIGURE 2–20. Rotator cuff tendon weakness and inabilityto lift the arm.


ARTHROGRAPHY

CASE: This 71-year-old woman presented with recur-rent rotator cuff tendonitis. She presented with localsubacromial tenderness, a painful arc at 70 de-grees, and pain and mild weakness when resistingmidarc abduction and external rotation. Herstrength improved modestly with the lidocaine injec-tion test. Arthrography demonstrated a complextear (the lower arrow). Dye entered the subacromialbursa (upper arrow) from the glenohumeral joint(the bursa and the synovial cavity to not communi-cate in the normal shoulder).

DIAGNOSIS: Full-thickness rotator tendon tear. Thesubacromial space measures 10 mm (normal 10 to11 mm), indicating a normal thickness rotator cufftendon.

DISCUSSION: The patient fully recovered with acombination of restricted reaching and lifting, thependulum stretch exercise, a subacromial injection of Depo-Medrol, and recovery toning exercises.The prognosis for full recovery depends on thethickness of the tendons (normal thickness indicatesno mucinoid degenerative thinning).

FIGURE 2–22. Arthrography to confirm a rotator cuff tendontear. Hypaque 60 injected into the glenohumeral joint leaksthrough a tear in the rotator cuff and into the subacromial bursa.

SHOULDER MRI

CASE: This right-handed, 55-year-old constructionworker fell 5 to 6 feet onto concrete, striking hisright side and right shoulder. He felt immediatepain so severe he could not raise his arm up with-out the help of his left arm. Testing of midarc ab-duction and external rotation strength was impossi-ble due to pain. Plain x-rays did not disclose afracture or dislocation.

DIAGNOSIS: Acute rotator cuff tendon rupture withmuscle retraction.

DISCUSSION: Given the type of injury, the profoundchanges on examination, and the risk of an acutetendon rupture, MRI was the test of choice in this la-borer with profound loss of shoulder function on thedominant side. The patient underwent acute surgi-cal intervention to repair the torn tendon. Criteriafor surgical treatment of rotator cuff tears includedramatic loss of function, weakness of external rota-tion or abduction that approaches 50% and that isnot exaggerated by concurrent rotator cuff ten-donitis pain, acute traumatic tears (a more favor-able outcome than the chronic mucinoid degenera-tive tears of older adults), dominant side, and nomedical contraindications.

FIGURE 2–23. Shoulder MRI showing supraspinatus tendontear with muscle retraction.

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BICEPITAL TENDONITIS Acute inflammation of the longhead of the biceps causes anterior shoulder pain, bicipital groovetenderness, and pain aggravated by resisting flexion at the elbow.Chronic inflammation of the biceps tendon can lead to bicipitaltendon rupture.

PALPATION

SUMMARY: Local tenderness is located directly overthe bicipital groove and is palpable approximately1 inch down from the anterolateral tip of theacromion. Tenderness is invariably present but notabsolutely necessary for the diagnosis.

MANEUVER: The bicipital groove is identified byplacing a finger on the anterolateral humeral headbetween the greater and lesser tubercles. Passive ro-tation of the arm aids in the identification as thegreater and lesser tubercles are felt moving underthe fingertip.

ADDITIONAL SIGNS: Pain aggravated by flexion ofthe elbow, isometrically performed; a positive pas-sive painful arc maneuver if impingement is present(see Figure 2–6); a bulge in the antecubital fossa,signifying long head tendon rupture; and preservedstrength of elbow flexion despite tendon rupture.The strength of the unaffected short head of the bi-ceps and the brachioradialis muscles combine tomake up 80% of the strength of elbow flexion.

INTERPRETATION: Each patient is examined forswelling and inflammation of the long head of thebiceps in the bicipital groove, for signs of tendonrupture, and for associated subacromial impinge-ment. Bicipital tendonitis is less common than rota-tor cuff tendonitis.

FIGURE 2–24. Palpation of the bicipital groove for bicipitaltendonitis.


BICIPITAL TENDONITIS

SUMMARY: The ribbon-like long head of the bicepslies in the bicipital groove and is susceptible to in-flammation and tendon rupture. It is the third mostcommon form of tendonitis at the shoulder. It ranksbehind tendonitis of the supraspinatus and infra-spinatus tendons.

POSITIONING: Sitting, relaxed shoulder, hand onthe leg.

SURFACE ANATOMY: Anterior humeral head, lesserand greater tubercles, anterolateral corner of theacromion.

POINT OF ENTRY: Between the lesser and greatertubercles of the humerus, 1 inch below the antero-lateral corner of the acromion.

ANGLE OF ENTRY: Perpendicular to the skin.



ANESTHESIA: Ethyl chloride, skin: 1 mL, deltoid; 1 mL, bicipital groove.

FIGURE 2–25. Bicipital tendonitis confirmed by local anes-thetic placed at the bicipital groove.

BICIPITAL TENDON RUPTURE

CASE: This 64-year-old man on coumarin had a“spontaneous” rupture of the right long head of thebiceps. He denies injury, a fall to an outstretchedarm, or unusual lifting. Note the extensive bruisingfrom his coumarin. His international normalized ratio was 3.7 at the time of presentation.

DIAGNOSIS: Acute rupture of the long head of thebiceps on the right side and an old bicipital ruptureon the left.

DISCUSSION: Complete bicipital tendon rupturescause the typical “Popeye” deformity in the antecu-bital fossa and often are associated with extensiveecchymosis. Although dramatic in appearance,these are rarely repaired. The short head of the biceps and the brachioradialis are responsible for 80% to 85% of the strength of elbow flexion.FIGURE 2–26. Bicipital tendon rupture confirmed by clinical

examination.

SHOULDER 37

AC JOINT OSTEOARTHRITIS AND SEPARATION Thediagnosis of AC arthritis or separation is readily made based onits characteristic focal tenderness; in fact, patients readily identifythe AC joint by pointing directly to it when describing their ante-rior shoulder pain. Osteoarthritis is a nearly universal occurrencewith advancing age. Injury to its supporting ligaments is calledshoulder separation.

PALPATION OF THE AC JOINT

SUMMARY: The diagnosis of AC osteoarthritis or shoulder separation—injury to the supporting ligaments—is based on the demonstration of focal tenderness over the anterosuperior portion of thejoint. Arthritis is further characterized by the degreeof bony enlargement. AC separation is defined asfirst, second, or third degree based on the radio-graphic measurement of bony separation.

MANEUVER: The anterior, lateral, and posterioredges of the acromion are marked with a pen. TheAC joint is located along the anterior portion ofthe acromion, approximately 13⁄4 inches from itslateral edge.

ADDITIONAL SIGNS: Bony enlargement defines thedegree of osteoarthritis. Downward pressure on thearm to displace the joint defines the degree of ACseparation. Pain can be reproduced by passivelyadducting the arm across the chest, forcing theends of the articulating bones together. If the condi-tion is severe, pain can be reproduced by activelyresisting the biceps; the action of the biceps gener-ates traction across the joint.

INTERPRETATION: Local tenderness combined withbony enlargement defines the degree of osteoarthri-tis. Local tenderness occurring after injury but withthe normal alignment of the acromion and clavicledefines first-degree AC separation. Local tendernessoccurring after injury with widening of the jointwhen downward traction is placed on the joint de-fines a second-degree AC separation. Third-degreeseparations are obvious to inspection; the clavicleis abnormally positioned above the plane of theacromion.

FIGURE 2–27. Palpation of the AC joint.


AC JOINT OSTEOARTHRITIS

CASE: This middle-aged plywood mill worker com-plained of anterior shoulder pain and pointed tothe AC joint as the most sensitive area of his shoul-der. He has pain with reaching overhead andwhen he rolls onto his right side during the night.

DIAGNOSIS: AC joint osteoarthritis with inferiorlydirected osteophytes.

DISCUSSION: Osteoarthritis of the AC joint is a uni-versal condition, developing in nearly all patientsolder than 50 years. However, only 5% ever de-velop symptoms. The diagnosis is suggested by an-terior shoulder pain, focal tenderness directly overthe joint, and bony enlargement. The diagnosis isconfirmed by x-ray or by anesthetic placed just overthe joint. Large inferiorly directed osteophytes cancause rotator cuff tendonitis; the supraspinatus ten-don is positioned directly under the AC joint.

FIGURE 2–28. AC joint osteoarthritis is confirmed by plainx-rays.

LOCAL ANESTHETIC BLOCK OF THE AC JOINT

SUMMARY: Occasionally patients present with acombination of symptoms suggesting simultaneousinvolvement of the AC joint and rotator cuff ten-donitis, two common shoulder conditions. Localanesthetic block is used to determine the role of theAC joint in the patient’s clinical presentation. Theneedle enters just over the end of the clavicle (11⁄2inches medially to the lateral edge of theacromion).


DEPTH: 3⁄8 to 5⁄8 inches, down to the periosteum ofthe clavicle.

VOLUME: 1 mL anesthetic and 1⁄2 mL K40.

NOTE: The needle does not enter the joint directly.The injection is placed just under the synovial mem-brane attached to the distal clavicle.

FIGURE 2–29. Local anesthetic block of the AC joint toconfirm osteoarthritis and first-degree separation.

SHOULDER 39

shoulder on examination. The diagnosis is made by the character-istic changes seen on routine x-rays, including asymmetrical nar-rowing of the cartilage, increased bony sclerosis, and the uniqueosteophyte formation that projects inferiorly off the humeral head.

ANTERIOR SHOULDER SWELLING

SUMMARY: Active arthritis of the glenohumeral jointis not common.

MANEUVER: The coracoid process, the AC joint,and the humeral head are palpated and marked.Glenohumeral joint swelling and its accompanyingjoint line tenderness are located in the infraclavicu-lar fossa just lateral to the coracoid process.Swelling ranges from subtle filling in of the fossa toanterior enlargement, often seen best by inspectingthe shoulder from above, looking down.

ADDITIONAL SIGNS: The range of motion in all di-rections can be limited, depending on the acute-ness of the process. Joint line tenderness locatedjust under the coracoid process can be elicited bypalpation in a superior and slightly lateral direc-tion. Crepitation is evident with active movement ofthe shoulder either passively or against resistance(osteoarthritis). Signs of inflammation are notablyabsent because of the depth of the joint.

INTERPRETATION: Osteoarthritis and rheumatoidarthritis are the most common causes of glenohumeraljoint swelling. The severity correlates directly with theloss of range of motion, particularly in external rota-tion and abduction. Septic arthritis is rare. Patientswith acute bacterial infections cradle their arm and do not allow any movement in any direction.

FIGURE 2–31. Anterior shoulder swelling characteristic ofa swollen glenohumeral joint.

THIRD-DEGREE AC SEPARATION

CASE: This 35-year-old mountain biker fell forwardover the handlebars after striking a rock. His shoulderstruck the ground. The direct blow to the anterior shoul-der caused immediate shoulder pain and deformity.

DIAGNOSIS: Third-degree AC separation.

DISCUSSION: The acromioclavicular, coracoclavicu-lar, and coracoacromial ligaments are attachedtightly to the periosteum and hold the acromion,clavicle, and coracoid together. Falls to an out-stretched arm, a dramatic blow to the anterior shoul-der (tackling in football), or a fall landing directlyon the anterior portion of the shoulder can causethe ligaments to be sprained, partially torn, or com-pletely disrupted (first-degree sprain and second-and third-degree AC separations, respectively).

FIGURE 2–30. Third-degree AC separation confirmed byplain x-rays.

GLENOHUMERAL OSTEOARTHRITIS Osteoarthritis of theglenohumeral joint is an uncommon problem. Most cases are pre-ceded by a history of shoulder injury, either recent or remote. Thediagnosis often is overlooked because of its similarity to frozen


GLENOHUMERAL JOINT OSTEOARTHRITIS

CASE: A 67-year-old rancher’s wife presents withanterolateral shoulder pain and stiffness over several years. She denies any history of fracture,dislocation, or severe injury. However, she states,“People say I’ve always done a man’s work. Itdoesn’t surprise me that it is arthritic, since arthritisruns in my family.”

DIAGNOSIS: Glenohumeral osteoarthritis.

DISCUSSION: Arthritis of the glenohumeral joint ischaracterized by a loss of articular cartilage be-tween the humeral head and the glenoid, osteo-phyte formation extending from the inferior portionof the humeral head, and humeral head sclerosis.Note that the combination of the loss of articularcartilage and osteophyte formation transforms thenormally round humeral head into the characteristicclublike deformity.

FIGURE 2–32. Glenohumeral joint osteoarthritis con-firmed by plain x-ray of the shoulder.

GLENOHUMERAL JOINT OSTEOARTHRITIS

SUMMARY: Intra-articular injection enters 1⁄2 inchbelow the coracoid process and is directed out-ward toward the medial portion of the humeralhead. Err toward the superior aspect of the joint to avoid the neurovascular bundle of the axilla.

NEEDLE: 11⁄2 inch to 31⁄2 inch spinal needle, 22 gauge.

DEPTH: 11⁄2 to 21⁄2 inches, down to periosteum of the humeral head or glenoid.

VOLUME: 3 to 4 mL anesthetic and 1 mL K40.

NOTE: Fluoroscopy is strongly recommended inobese patients.

FIGURE 2–33. Glenohumeral joint osteoarthritis con-firmed by aspiration of the shoulder.

SHOULDER 41

APPREHENSION TEST

SUMMARY: The combination of an abnormal sulcussign with an abnormal apprehension test (anteriormovement of the humeral head) confirms the diag-nosis of multidirectional instability.

MANEUVER: The patient’s arm is carefully raised tothe level of the shoulder. With one hand applyinggentle pressure from behind, pressure is applied tothe flexed elbow, rotating the shoulder externally.Apprehension experienced by the patient or ante-rior movement of the humeral head felt by the ex-aminer strongly suggests anterior subluxation of theshoulder.

ASSOCIATED SIGNS: Crepitation or a clicking can bedemonstrated in some patients with passive circum-duction of the shoulder. Anteroposterior movement ofthe humeral head (translation) can be demonstratedby forcefully grasping the humeral head and movingit in the anterior and posterior directions while hold-ing the acromion in a fixed position. Extremely looseshoulders may be dislocated in the office.

FIGURE 2–35. Apprehension test for multidirectional instabil-ity of the shoulder.

SUBLUXATION A loose glenohumeral capsule, a poorly devel-oped deltoid muscle, and insufficiency of the rotator cuff tendons allcontribute to the instability of the ball-and-socket joint and its suscep-

SULCUS SIGN

SUMMARY: The deltoid muscle arises from theacromion and attaches to the midhumerus. Thesupraspinatus tendon attaches to the greater tuber-cle. Downward movement of the humeral head isrestricted by the tone and bulk of the deltoid, thetone and thickness of the supraspinatus tendon, andthe redundancy of the glenohumeral capsule. Thismaneuver is used to assess the looseness of theshoulder joint, the looseness of the subacromialspace (subluxation), and the patient’s potential tolerance of the pendulum stretch exercise.

MANEUVER: The patient is asked to relax the shoul-der. One hand is placed atop the acromion, and onehand is placed in the antecubital fossa. Downwardpressure is applied to the arm to open the subacro-mial space. The examiner assesses the looseness ofthe shoulder and the discomfort of the maneuver.

INTERPRETATION: A tight shoulder—no movementwith downward pressure—is seen with extremeguarding or tension due to pain, frozen shoulder, fibromyalgia, or an overly developed deltoid.Downward movement of 1⁄4 inch is considered aver-age looseness. Downward movement of more than1⁄2 inch indicates hypermobility (subluxation). Whenthis downward displacement is accompanied by anabnormal movement of the humeral head in the an-teroposterior direction, the term multidirectional in-stability is applied.

FIGURE 2–34. Subluxation or hypermobility is confirmedby the sulcus sign on clinical examination.

tibility to dislocation. Patients often describe a general looseness to thejoint, anxiety when the shoulder is placed in the extremes of range ofmotion, and variable degrees of subluxation or frank dislocation.


SUBSCAPULAR BURSITIS Exaggerated scapulothoracicmovement associated with loss of normal glenohumeral mobilitycauses friction between the bony thorax and the underside of thescapula. Subscapular bursitis is associated primarily with frozen

shoulder, glenohumeral osteoarthritis, or any other condition limit-ing the normal range of motion of the shoulder. The diagnosis isbased on localized tenderness just under the superomedial angle of the scapula at the level of the second and third rib.


OBJECTIVE: Local tenderness atop the second andthird ribs directly under the superior medial angle ofthe scapula is the hallmark of subscapular bursitis.

MANEUVER: The ipsilateral arm is fully abducted;the patient is asked to place the hand on the con-tralateral shoulder. The superior medial angle of thescapula and the center of the ribs are marked witha pen. Bursal tenderness is palpated directly overthe rib closest to the angle of the scapula.

ADDITIONAL SIGNS: Levator scapula, rhomboid,and trapezius muscle tenderness and spasm oftenaccompany acute bursitis. A snapping sensation orpopping may be evident with circumduction of theshoulder. Signs of primary shoulder or neck disor-ders may be present on exam.

INTERPRETATION: A half dollar–sized area of ten-derness at the superior medial angle is most com-monly caused by subscapular bursitis as opposedto the generalized muscular tenderness of the strainof the upper back muscles. Primary involvement ofthe rib or the scapula must be considered in thecase of the patient with a known primary cancer(e.g., breast, lung, prostate).



SUMMARY: Local anesthetic block is used to distin-guish subscapular bursitis from upper back muscu-lar strain, referred pain from the neck, and primaryinvolvement of the bony thorax.

Enter directly over the second or third rib, whicheveris closest to the superomedial angle of the scapula.


DEPTH: 3⁄4 to 11⁄4 inch down to the periosteum of the rib.

VOLUME: 1 to 2 mL anesthetic, 1 mL K40, or both.

NOTE: Place one finger above and one finger be-low the rib in the intercostal spaces and directlyover the center of the rib. Never advance the needle more than 1 to 11⁄4 inches (pleura).

FIGURE 2–37. Local anesthetic block of the subscapularbursa.

SHOULDER 43

SHOULDER PAIN REFERRED FROM THE NECK Trapezialcervical strain and cervical radiculopathy account for 15% of pa-tients who complain of shoulder pain.

BODY LANGUAGE

SUMMARY: Approximately 15% of patients com-plaining of shoulder pain have a neck or upperback muscle source of their pain. Furthermore, patients with moderate to severe rotator cuff ten-donitis, glenohumeral arthritis, or higher-degree AC separations can have concomitant cervicalstrain; the supporting muscles of the neck flare with the tension and pain caused by the shoulder.Patients whose pain is aggravated solely by neckrotation or lateral bending rather than shoulderreaching, pushing, pulling, and lifting usually havean isolated cervical strain or cervical radiculopathy.Note that each of the three lowest cervical rootscan refer pain over the shoulder or the upperscapular area.

FIGURE 2–38. Body language of the patient complaining of primary neck symptoms.

CERVICAL SPINE MRI

CASE: This 43-year-old woman complained of anacute onset of arm pain, numbness of the fingers,and stiffness of the neck. The pain radiated fromthe base of the neck, through the shoulder, downthe arm, and into the hand. She experienced con-stant numbness and tingling of the first three digits.Her examination showed paraspinal tenderness be-tween the spinous and transverse processes of thelower neck, endpoint stiffness with guarding whenrotating the neck to the affected side, weakness ofelbow flexion, and a diminished bicipital reflex.

DIAGNOSIS: Cervical radiculopathy due to a C5–6disk herniation.

DISCUSSION: Cervical radiculopathy due to disk her-niation should be suspected in the younger patientwith acute symptoms, sensorimotor findings on neu-rologic examination, or cervical radiculopathy empir-ically treated with manual traction but with a poorresponse.

FIGURE 2–39. Cervical spine MRI confirming a herniated nu-cleus pulposus.


SHOULDER PAIN REFERRED FROM THE CHEST ORABDOMEN Referred pain to the shoulder from a medical condi-tion in the chest or abdomen is nearly always distinguished by thecharacteristic associated symptoms of cough, nausea, and palpitation.

SHOULDER PAIN

CASE: This 24-year-old suffered a fall from a ladderlanding on the left side of the chest. Immediatepain developed along the chest wall, followed by chest and shoulder pain aggravated by deepbreathing.

DIAGNOSIS: Fractured ribs number 7 and 8, hemothorax, pneumothorax, and subcutaneous emphysema.

DISCUSSION: Approximately 1% of shoulder painis caused by primary involvement of the heart,great vessels, lungs, pleura, or upper abdomen.These nonskeletal diagnoses are readily identifiedby the associated symptoms that accompany theshoulder pain, reflecting the abnormal function ofthe major organ system.

FIGURE 2–40. Shoulder pain referred from the pleura andlung.


EXAMINATION MANEUVERS DIAGNOSIS CONFIRMATION PROCEDURESIsometrically performed resisted midarc abduction 1. Rotator cuff tendonitis Local anesthetic placed in the subacromial bursa; no

or external rotation significant muscle weakness

The passively performed painful arc maneuver

Local subacromial tenderness

The passively performed painful arc maneuver 2. Impingement syndrome Local anesthetic placed in the subacromial bursa


Weakness of midarc abduction or external rotation Rotator cuff tendonitis Local anesthetic placed in the subacromial bursa with with tear persistent muscle weakness

Isometrically performed resisted midarc abduction or external rotation

The passively performed painful arc maneuver


Loss of external rotation or abduction with Frozen shoulder Local anesthetic placed in the subacromial bursa with endpoint stiffness persistent loss of range of motion

Abnormal Apley scratch sign No radiographic evidence of glenohumeral arthritis

Inability to reach overhead

Loss of external rotation or abduction with Glenohumeral Radiographic evidence of glenohumeral arthritisendpoint stiffness osteoarthritis

Abnormal Apley scratch sign


Bicipital groove tenderness Bicipital tendonitis Local anesthetic placed in the bicipital groove

Pain aggravated by resisted elbow flexion

“Popeye” deformity in the antecubital fossa Rupture of the long head Examinationof the biceps



�Sulcus sign with downward traction applied Multidirectional instability Examinationat the elbow of the shoulder

(subluxation)

Abnormal anteroposterior movement of the humerus (translation)

Apprehension with passive rotation of the shoulder

Bony enlargement of the AC joint AC joint arthritis Shoulder series x-ray

Local tenderness at the AC joint

Pain aggravated by passive adduction

Local tenderness at the AC joint AC joint injury Weighted views of the shoulder or local anesthetic placed overthe AC joint

Pain aggravated by passive adduction 1st-degree separation

AC joint opens with traction applied at the elbow 2nd-degree separation

AC joint deformity: the clavicle is elevated above 3rd-degree separationthe acromion

Local tenderness at the SC joint SC joint arthritis Apical lordotic views of the chest, local anesthetic placed over the SC joint

Pseudoenlargement of the clavicle

Tenderness under the superior medial angle Subscapular bursitis Local anesthetic placed over the adjacent 2nd or 3rd ribof the scapula

No tenderness of the rhomboid or levator scapula muscles

SHOULDER 45


COMMON SHOULDER FRACTURES

SUMMARY

Fractures of the shoulder are not common, and those thatdo occur are seen in very specific age groups. Fractures ofthe humerus constitute approximately 2% of all fractures.The incidence increases with age and with osteoporosis (es-pecially in the humeral neck). Humeral fractures are classi-fied according to location: proximal neck, humeral shaft,and supracondylar. The proximal neck and humeral shaftfractures are grouped together, separate from the supra-condylar fractures, because they are usually treated nonop-eratively. Supracondylar fractures are more complex, caninvolve the elbow joint, and may necessitate open fixation.

Fracture of the clavicle is the most common fracture ofchildhood and is a very common fracture in shoulder gir-dle trauma in adults. These fractures are classified accord-ing to location (proximal-, middle-, and distal-third frac-tures), involvement of the adjacent articular cartilage of theSC or AC joint, and position of distal fractures relative tothe coracoclavicular ligaments. Fracture of the middle thirdis the most common (80%). The second most commonfracture is the interligamentous, nondisplaced fracture ofthe distal third (10%).

Displacement of the clavical fracture fragments dependson the pull of the sternocleidomastoid muscles (the proxi-mal fragments are pulled superiorly) and the pectoralis ma-jor muscles (the distal fragments drop forward).

SHOULDER DISLOCATION

SUMMARY: Dislocation of the shoulder is not com-mon. Multidirectional instability of the shoulder, rotator cuff insufficiency from chronic tendonitis,and rotator cuff tears are predisposing factors. Dislocations are classified as anterior, posterior, or inferior. The anterior dislocation is most com-mon. Seventy percent occur in patients less than 30 years old.

REDUCTION AND IMMOBILIZATION: The threemethods for reduction are the traction–countertrac-tion, Hennipen, and Stimson methods. All requireintravenous sedation with narcotics and a musclerelaxant. After successful reduction, a shoulder im-mobilizer or sling and swath immobilization is usedfor 3 weeks. This is followed by range of motionexercises to prevent frozen shoulder.

SURGICAL REFERRAL: Referral is necessary for rota-tor cuff tears, fracture of the greater tuberositylarger than 1 cm, and glenoid rim fractures dis-placed more than 5 mm.

PROGNOSIS: The most common complication is recurrent dislocation (60%). Other complications include rotator cuff tears, greater tuberosity frac-ture, glenoid rim fracture, axillary nerve damage,brachial plexus damage, humeral head fracture,and biceps rupture.

FIGURE 2–41. Shoulder dislocation.

SHOULDER 47

GREATER TUBERCLE FRACTURE

SUMMARY: This 72-year-old woman fell and frac-tured the greater tubercle of the humeral head,which failed to heal, and normal anatomic align-ment was not achieved. The abnormality has led tochronic impingement with an inability to abduct theshoulder more than 60 degrees. Surprisingly, shenever developed any clinical episodes of rotatorcuff tendonitis.

IMMOBILIZATION: The patient was treated with along arm hanging cast with collar and cuff followedby physical therapy exercises.

SURGICAL REFERRAL: Acromioplasty is the treatmentof choice for chronic impingement.

PROGNOSIS: The patient declined surgical interven-tion; she has adjusted to her postfracture limitations.

FIGURE 2–42. Greater tubercle fracture of the humeralhead.

FRACTURES OF THE HUMERAL NECK

SUMMARY: Proximal neck fractures are classified astwo-part, three-part, or four-part fractures with or with-out dislocation of the shoulder joint (Neer classifica-tion). Humeral shaft fractures are classified by frac-ture line (spiral, transverse, longitudinal, comminuted)and by location relative to the pectoralis and deltoidinsertions.

IMMOBILIZATION: Neck fractures are treated witha long arm hanging cast with collar and cuff fol-lowed by physical therapy exercises. The cast isadjusted by lengthening the sling and its position at the wrist to correct for any angulation.

SURGICAL REFERRAL: Internal fixation is necessaryfor neck fractures showing dislocation of the shoul-der, fragment displacement greater than 1 cm, orfragment angulation greater than 45 degrees andfor shaft fractures that are open, severely commin-uted, or transverse (where there is a higher degreeof nonunion).

PROGNOSIS: Complications include frozen shoul-der (proximal neck fractures), chronic impingement(angulation of the greater tubercle), osteoarthritis ofthe shoulder (fracture or dislocation), radial nerveinjury (lower-third shaft fractures), brachial artery in-jury (shaft fractures), nonunion (transverse and com-minuted shaft fractures).

FIGURE 2–43. Fractures of the humeral neck.


CLAVICLE FRACTURES

SUMMARY: Fractures of the clavicle are classifiedaccording to location: proximal, middle, and distalthird. Fractures of the proximal third are classifiedas nondisplaced, displaced, or intra-articular.

All middle-third fractures are grouped together.

Fractures of the distal third are classified according todisplacement, location relative to the coracoclavicu-lar ligaments, and whether the fracture line entersthe AC joint.

IMMOBILIZATION: The shoulder is immobilized in asimple sling or figure-of-eight splint, and adjust-ments are made in order to maintain close approxi-mation of the fragments.

SURGICAL REFERRAL: Surgery must be consideredin the case of any fracture associated with first rib,pneumothorax, or neurovascular injury (less than3%); in distal third fractures with displacement (because of the greater risk of nonunion); and inpoorly healing fractures that are complicated byshoulder dysfunction or chronic pain.

PROGNOSIS: Complications include dislocation of the AC or SC joint; head and neck injuries (dis-placed fractures); first rib fracture; pneumothorax(3%); brachial plexus injury (caused by severe andforceful blows in a downward direction); subcla-vian vessel or internal jugular vein injuries (causedby rare, severe blows); nonunion, which is rare;and malunion with cosmetic deformity, which iscommon.

FIGURE 2–44. Clavicle fractures.

SHOULDER 49

• Impingement is a universal problem.• Impingement syndrome, as a separate diagnosis, is

determined by the two impingement maneuvers: thepainful arc maneuver and subacromial tenderness.

• Impingement signs are always present with active rota-tor cuff tendonitis.

• Subtle impingement can be brought out by internallyrotating the upper arm (thumb down), bringing thegreater tubercle into closer contact with the undersur-face of the acromion.

• Active rotator cuff tendonitis is distinguished frompure impingement syndrome by the isometric resis-tance testing of the individual rotator cuff tendons(i.e., resisting midarc abduction, as in supraspinatustendonitis).

• The patient’s susceptibility to impingement correlatesdirectly with the acromial angle.

• The subacromial bursa and the synovial cavity of theshoulder are not connected. The two fluid-filled struc-tures are separated by the rotator cuff tendons.Radiopaque dye injected into the synovial cavity willenter the subacromial bursa only when a full-thicknesstear in the supraspinatus or infraspinatus is present.

• Common shoulder tendonitis accounts for 70% of allshoulder diagnoses.

• Common shoulder tendonitis most often affects thesupraspinatus tendon; of the four rotator cuff tendons,it is the most susceptible to impingement because of itsunique anatomic position between the acromialprocess and the humeral head.

• Uncomplicated rotator cuff tendonitis is a tendon in-flammation that is not complicated by frozen shoulder

CLINICAL PEARLS

(10%), AC joint osteoarthritis (5%), rotator cuff ten-don tear (1% to 2%), or glenohumeral arthritis (lessthan 1%).

• Risk factors for rotator cuff tendon tear include muci-noid degenerative thinning of the tendon, a narrowedsubacromial space on plain x-rays of the shoulder, a fallto an outstretched arm or directly onto the shoulder,weakness of external rotation or abduction that is notattributable to pain, multiple episodes of recurrent orchronic tendonitis, a previous tendon rupture, sys-temic steroids, rheumatoid arthritis or other connec-tive tissue disease, and improper placement of a corti-costeroid injection.

• Four diagnostic tests are used to confirm a rotator cufftendon tear: the subacromial lidocaine injection test,which relieves pain and demonstrates persistent weak-ness; arthrography of the glenohumeral joint; diagnos-tic ultrasound; and MRI.

• The clinical examinations of frozen shoulder andglenohumeral osteoarthritis are identical. Shoulder x-rays are normal with pure frozen shoulder anddemonstrate cartilaginous wear, osteophytes, and sub-chondral sclerosis with osteoarthritis.

• Whereas osteophyte formation is variable in os-teoarthritis of the hip, knee, back, and neck, 99% of pa-tients with osteoarthritis of the glenohumeral jointdemonstrate spurring off the inferior aspect of thehumeral head.

• AC joint arthritis is a universal problem, increasing infrequency with increasing age.

• SC swelling and subluxation are nearly always misin-terpreted as an enlarged proximal end of the clavicle.

50

CHAPTER 3: UPPER BACK


Diagnoses

Upper back muscular strain (most common diagnosis)StressDorsokyphotic posture

Fibromyalgia

ScoliosisReactive muscular strain

Radiculopathy

Thoracic spine radiculopathyVertebral body fracture

Spinal cord injury or tumorHerniated nucleus pulposusOsteomyelitis or epidural process

Posterior chest wallRib contusion or fractureEpidemic pleurodynia

Subscapular bursitis

Referred painCervical radiculopathyPrimary lung disease (e.g., pneumonia,

pulmonary embolus)Thoracic aortic aneurysmTakayasu’s arteritisCoronary arteries

Confirmations

Socioeconomic or psychological issuesTypical posture seen in older adults or in patients

with depressionConfirmation by exam: multiple trigger points;

normal labPosteroanterior and lateral full-length spine x-raysThe underlying spinal column, nerves, or cord

pathologyNeurologic testingBone scan or magnetic resonance imaging (MRI)

X-ray: thoracic spine x-raysBone scan or MRIMRIMRIMRI

Chest and tangential rib x-raysLocal anesthetic block


Neck x-rays, MRI, electromyographyChest x-ray, lung scan, computed tomography scan

Chest x-rayErythrocyte sedimentation rate, angiogramElectrocardiogram, creatine phosphokinase,

angiogram

UPPER BACK 51

INTRODUCTION Upper back muscular strain is thedominant condition affecting the thoracic spine area.Muscular strain caused by tension, stress, dorsokyphoticposture, or whiplash is nearly as common as its analogouscondition in the neck, cervical strain. This condition oftenovershadows the much less common intrinsic thoracicspine conditions. Less common conditions affecting theupper back pain include posterior rib and intercostal mus-cle injuries and the conditions that affect primarily the lungand pleura. As opposed to arthritis of the cervical and lumbar spine, arthritis of the thoracic spine is unusualoutside the setting of primary scoliosis and the inflamma-tory spondyloarthropathies.

The diagnosis of an uncomplicated upper back muscularstrain caused by tension, stress, or poor posture is not dif-ficult. Signs and symptoms are limited to the supportingmuscles of the upper back, including the trapezius, levatorscapula, and rhomboid muscles. The muscles are tender,and the movement of the upper back is limited by muscu-lar spasm in the case of an uncomplicated muscular strain.There is a conspicuous absence of bony tenderness andradicular signs. This is in stark contrast to reactive muscu-lar strain that is the direct result of an underlying threat tothe spinal column. As with the intrinsic conditions affect-ing the cervical and lumbar spine, any condition threaten-ing the bony integrity of the spinal column, the functionof the spinal nerve, or the integrity of the spinal cordcauses severe degrees of muscle spasm and focal midlinetenderness. In assessing the patient with upper back mus-cular symptoms, the challenge to the primary care provideris to distinguish simple upper back muscular strain fromthe severe reactive muscle spasm that represents the body’sresponse to a serious underlying neurologic process.

Intrinsic conditions affecting the upper back, includingvertebral body compression fracture, osteomyelitis andepidural abscess, metastatic involvement of the vertebralbody, and other fractures of the spinal column, are themost serious conditions in the differential diagnosis ofupper back pain. Fortunately, these conditions are notcommon. They are identified by focal, midline tendernessover the spinous processes, severe reactive muscularstrain, and radicular pain radiating around the chest wall.

Pain referred to the upper back is common. Pneumonia,pulmonary embolus, thoracic aortic aneurysm, and rarelyprimary heart disease cause varying degrees of back pain. Inaddition, each of the lower cervical roots has an expressionof pain over the scapula and posterior shoulder areas. Thediagnosis of the early presentation of spinal nerve compres-sion from spinal levels C5 through C7 can be very elusive.These minor sensory radiculopathies cause a vaguely de-scribed pain over the upper back that may not necessarily be accompanied by a significant degree of paresthesias orhypesthesias.

Subscapular bursitis, a unique inflammation betweenthe scapula and the underlying ribs, is an uncommon causeof upper back pain. It is typically secondary to loss of nor-mal function at the shoulder or a reflection of intrinsic dis-ease of the cervical spine.

SYMPTOMS Conditions directly affecting the upperback cause pain, tension, and muscle spasm.

Diffuse upper back pain is the most common pain pat-tern. This pattern results from the irritation and spasm ofthe one or both of the muscular layers that cover the bonythorax and scapula. The three divisions of the trapeziusmuscle—the superior, middle, and lower—form the outer-most layer and the rhomboid major, rhomboid minor,and levator scapula muscles form the inner layer. The su-perior division of the trapezius is the most commonly af-fected muscle. Its characteristic pain is centered approxi-mately halfway between the cervical spinous processesand the acromion. By contrast, the pain caused by spasmof the rhomboids or levator scapula muscles is deeperand described vaguely between the scapulae, typicallycentered between the spinous processes and the medialborder of the scapula. This clinical presentation is nearlyidentical to the pain arising from muscle spasm from themiddle and lower divisions of the trapezius. Most casesof upper back muscular spasm are caused by poor posture,stress, or fibromyalgia. In a minority of cases muscularsymptoms reflect an underlying intrinsic process affectingthe thoracic spine. Reflex muscular spasm may be a signof structural disease of the spine (scoliosis, kyphosis, orcompression fracture) or infiltrative disease (e.g., metasta-tic disease, osteomyelitis).

Focal upper back pain, the size of a half dollar and locatednear the top of the scapula, is the classic presentation of sub-scapular bursitis. This is a friction point between the superiormedial angle of the scapula and the underlying ribs. Its clini-cal presentation is identical to the pain pattern and local ten-derness of levator scapula muscular strain. Local anestheticplaced either at the level of the rib or within the levatorscapula muscle is necessary to distinguish the two conditions.

Sharp pain aggravated by coughing or lying on the sidesis characteristic of pain arising from the bony thorax (ribs,costal cartilage, or sternum). Pain arising from these localmusculoskeletal areas must be distinguished from the painarising from the underlying lungs (e.g., pleurisy, pneumonia,pulmonary embolus) or vascular structures (aortic aneurysm).

Upper back pain without local tenderness (e.g., not ag-gravated by direct pressure, massage fails to identify a pres-sure point) is most often referred from the direct irritationof the cervical nerve roots. All three lower cervical spinalnerves refer pain over the scapula or posterior aspect of thedeltoid muscle. This referred pain from cervical radiculopa-thy that is unassociated with hand paresthesias or an upperextremity lancinating pain often is overlooked by manyhealth care providers and mistakenly diagnosed as a mildupper back muscular strain.

Central upper back pain is characteristic of involvementof the spinal column. Compression fracture, osteomyelitisof the vertebral body, epidural abscess, or metastatic lesionsinvolving the vertebral body present with varying degrees ofpain and spinal nerve irritation. The combination of centralback pain and pain that radiates around the chest wallshould always suggest either thoracic radiculopathy or thepreeruptive phase of shingles.


EXAMINATION The examination of the upper back be-gins with general observations of the patient’s movement,resting posture, and breathing pattern. Cautious movement,poor posture, and labored breathing define the involvementof the chest wall. Labored breathing associated with cough,frank shortness of breath, hemoptysis, and pleuritic-likepain demands full evaluation of the lungs, pleura, heart, andgreat vessels. Palpation of the classic trigger points locatedbetween the medial border of the scapula and the vertebralspinous processes identifies the degree of upper back mus-cular strain involving the trapezius, levator scapulae, andrhomboid muscles. Palpation of the second and third ribsjust under the superior medial angle of the scapula definesthe degree of subscapular bursitis. Palpation of the spinousprocesses of thoracic spine suggests an intrinsic process in-volving the spinal column (vertebral body compression frac-ture, osteomyelitis and epidural abscess, metastatic involve-ment of the vertebral body, and other fractures of the spinal

column). Finally, referred pain from the lungs, pleura, heart,or great vessels or the lower cervical nerve roots should beconsidered if the upper back pain is unassociated with localtenderness over the muscles or the adjacent bones.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL UPPER BACK FUNCTIONAND DIFFERENTIAL DIAGNOSIS

The next eight maneuvers represent the minimal examina-tion of the patient presenting with upper back symptoms.Function testing, height measurement, and screening ma-neuvers for muscle spasm, conditions affecting the bonythorax, and intrinsic conditions to the vertebral columnprovide enough information to triage to x-ray, order appro-priate labs, suggest general treatment recommendations, orproceed to more detailed examination and treatment.

GENERAL MOVEMENT

SUMMARY: Movement difficulties in the exam room,difficulty in performing simple tasks such as remov-ing a T-shirt, or the ease or difficulty in changingposition on the exam table can be the first clue tothe diagnosis of an upper back condition.

MANEUVER: Without prompting, the patient’s gen-eral movement is observed, including the ease ofmovement and the consistency of the arm and torsomotion.

INTERPRETATION: Cautious movement, general stiff-ness, and restricted movement of the upper back andneck are characteristic of significant muscle irritationand spasm. Great disparities between the examiner’sfirst observations of posture and general movementand function can be the clue to malingering.

FIGURE 3–1. General movement of the upper back.

1. Note the patient’s posture, the ease or difficulty inmoving from the chair to the exam table, and the pa-tient’s breathing pattern.

2. Perform a complete exam of the lung, pleura, and heartif back pain is accompanied by shortness of breath,pleurisy, cough, hemoptysis, or palpitations.

3. Palpate the trapezius, levator scapulae, and rhomboidmuscles.

ESSENTIAL EXAMINATION OF THE UPPER BACKBOX 3-1

4. Perform the chest compression test.5. Measure the patient’s height.6. Palpate the second and third ribs just under the supe-

rior medial angle of the scapula.7. Perform an essential exam of the neck if radiculopathy

is suggested.

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BREATHING PATTERN

SUMMARY: Splinting, shallow breathing, andpainful cough are clues to the conditions affectingthe bony thorax (the sternum, the costal cartilages,the ribs), the vertebral bodies, and the underlyinglung and pleura.

MANEUVER: Observations with and without distrac-tion are made of the patient’s ability to move aboutthe exam room, the ability to adjust the examina-tion gown, and the patient’s breathing pattern.

INTERPRETATION: Shallow breathing or splinting indi-cates chest wall injury, most commonly to the bony ribs,but is also characteristic of pleurisy, pneumonia, pul-monary embolism, and inflammatory pleural effusion.

FIGURE 3–3. Breathing pattern, splinting with injury to thethorax.

INSPECTION

SUMMARY: The normal curves of the back include cer-vical lordosis, thoracic kyphosis, and lumbar lordosis.The normal kyphotic curve can be affected by acutemuscular spasm, scoliosis, and compression fracture.

MANEUVER: The patient’s overall posture, the de-gree of thoracic kyphosis, and the position of thehead, neck, and upper back are inspected from theside. Then, the patient is asked to sit up as straightas possible, and the positions of the head, neck,and upper back are reassessed.

INTERPRETATION: Because age, depression, com-pression fracture, and scoliosis affect the normalthoracic kyphotic curve in the same way (exagger-ating the curve), radiographic studies are neces-sary to define the exact underlying cause.

FIGURE 3–2. Inspection of the patient’s upper back posture.


PALPATION OF THE TRAPEZIUS MUSCLE

OBJECTIVE: The trapezius muscle is divided into su-perior, middle, and lower third. Because of its inti-mate relationship with the neck and shoulder, mus-cular spasm most often affects the superior portion.Palpation of the upper third provides the optimalscreening of muscular spasm.

MANEUVER: Focal tenderness of the trapezius mus-cle usually is located halfway between the base ofthe neck and its attachment to the distal acromion.Firm pressure is applied at this site to determine thedegree of tenderness and muscular spasm.

INTERPRETATION: Acute trapezial spasm (intense local tenderness and moderate spasm) is seen withacute emotional or physical stress, cervical strainand radiculopathy, whiplash, and acute rotator cufftendonitis. Chronic symptoms (mild tenderness androck-hard muscular spasm) are characteristic of fibromyalgia, age-related dorsokyphotic posture,and chronic cervical radiculopathy.

FIGURE 3–4. Palpation of the trapezius muscle.


SUMMARY: The subscapular bursa is located under-neath the scapula, acting as a natural protectivepad between the ribs and scapula. For the exam-iner to palpate the bursa, the arm must be fully ab-ducted, moving the scapula laterally and thus ex-posing the underlying bursa.

MANEUVER: The superior medial angle of thescapula is marked with a pen. The patient is askedto place the hand on the contralateral shoulder (full adduction exposes the bursa). The ribs closestto the angle of the scapula are palpated for focal tenderness.

INTERPRETATION: A half dollar–sized area of ten-derness at the superior medial angle must be distin-guished from strain of the trapezius muscle, spasmof the levator scapulae and rhomboid muscles, andprimary involvement of the ribs.


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CHEST COMPRESSION TEST

SUMMARY: The bony thorax consists of the sternum,the costal cartilages, the ribs, and the vertebralbodies. Anteroposterior compression of the chest is the optimal screening maneuver to assess the integrity of the bony thorax.

MANEUVER: Compression of the chest wall is firstapplied in an anteroposterior direction. The palmareminences are placed over the middle of the ster-num and over the spinous processes of T5 and T6vertebra. The maneuver can be repeated with thepalms placed obliquely across the chest or fromside to side depending on response.

INTERPRETATION: A positive chest compression testis seen with any significant injury to the thorax, in-cluding rib contusions, rib fracture, nondisplacedrib fracture, costochondritis, and sternal fracture.FIGURE 3–7. Chest compression test to assess the integrity

of the bony thorax.

HEIGHT MEASUREMENT

SUMMARY: Height is determined by the curves ofthe back, the shape of the vertebral bodies, the in-tervertebral disk spaces, and posture. This is themost objective measurement of any condition thataffects the structural integrity of the spinal column.

MANEUVER: Serial heights should be performed in bare feet, with the patient standing as straightas possible.

INTERPRETATION: Serial loss of height is seen withnormal aging, degenerative arthritis, compressionfracture, and scoliosis. A decrease in height of 1⁄2inch over a 6- to 12-month period suggests that thepatient’s spinal disorder is progressing. Patientswith structural conditions affecting the spine, espe-cially scoliosis, should undergo repeat standing ra-diographs if height continues to decrease.

FIGURE 3–6. Height measurement to assess the integrity ofthe spinal column.



TRIAGE TO X-RAY The patient has a history of trauma,is at risk of bony injury, or has lost 1⁄2 inch of height in thelast 6 to 12 months:

• Order a chest x-ray and cardiogram if breathing is im-paired (pneumonia, pulmonary embolus, angina, coro-nary artery disease).

• Order a chest x-ray and tangential views of the ribs if thepatient has sustained a blow to the chest wall (rib contu-sion, rib fracture).

• Order a chest x-ray and thoracic spine views if focal ver-tebral pain and tenderness are noted on exam (compres-sion fracture, bony metastasis, osteomyelitis, andepidural abscess).

• Order posteroanterior and lateral films of the entire spineif the patient has lost 1⁄2 inch in height in the last 6 to 12months (scoliosis, compression fracture).

• Order a chest x-ray and thoracic spine films if the patientdescribes pain wrapping around the chest wall (compres-sion fracture, metastatic disease, epidural abscess, primarydisease of the spinal cord).

TRIAGE TO THE LAB For patients with back pain, fever,and significant respiratory insufficiency:

• Order a chest x-ray, complete blood cell count, erythro-cyte sedimentation rate, and blood cultures for patientswith acute back or chest pain, exquisite vertebral body ten-derness, or an acute change in respiratory function (pneu-monia, acute osteomyelitis, epidural abscess).

CONSIDER A BONE SCAN For patients with acutevertebral body pain, persistent rib pain, or chest wall painand a history of cancer (compression fracture, miscellaneousfractures of the spine, osteomyelitis, rib contusion or frac-ture, and metastatic disease).

CONSIDER MRI For patients with focal vertebral bodypain, radicular pain wrapping around the chest wall, or backpain and fever (compression fracture, miscellaneous frac-tures of the spine, osteomyelitis, and metastatic disease).

RECOMMEND EMPIRICAL TREATMENT The pa-tient has mild to moderate upper back pain and stiffness.Activities of daily living have not been affected. Symptomshave been present for less than 2 months. The breathingpattern is unaffected.

• Limit reaching, lifting, pushing, and pulling.• Attend to proper sitting posture.• Avoid stress.• Apply ice packs up to four times a day.• Prescribe a muscle relaxer for 7 to 10 consecutive nights.• Reexamine the patient if symptoms do not improve.

DETAILED EXAMINATION: SPECIFIC UPPERBACK DIAGNOSES

Perform a detailed examination of the upper back if the fol-lowing changes have occurred: The patient has persistent orchronic symptoms. There has been an injury. The patient’sheight has decreased by 1⁄2 inch over the course of the last 6to 12 months. Breathing is impaired, or respiratory functionhas deteriorated.

PALPATION OF THE VERTEBRAL BODY

SUMMARY: Patients with osteoporosis, known malig-nancy, or recent trauma are at the greatest risk ofdirect involvement of the vertebral body. Each indi-vidual spinous process must be palpated if the pa-tient describes midline back pain.

MANEUVER: Each spinous process is palpated withthe index finger. This is followed by gentle fist per-cussion of each vertebral level if tenderness is notelicited by palpation.

INTERPRETATION: Primary involvement of the verte-bral bodies is not common. Acute compression frac-tures occurring between thoracic level T12 and T7are most commonly due to osteoporosis or blunttrauma. Compression fractures occurring above tho-racic level T6 are uncommon and must be consid-ered pathologic (due to malignancy) until provenotherwise.FIGURE 3–8. Palpation of the vertebral body for focal

tenderness.

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MUSCULAR STRAIN OF THE TRAPEZIUS,RHOMBOIDS, OR LEVATOR SCAPULA Acute muscularstrain is the dominant diagnosis in the upper thoracic area. Theupper trapezius, rhomboids, and levator scapula are the most

commonly affected muscles. An exact anatomic diagnosis is basedon the characteristic points of focal muscular tenderness combinedwith local anesthetic placed in the muscle belly.

PALPATION OF THE LEVATOR SCAPULA AND RHOMBOID MUSCLES

SUMMARY: The levator scapula originates from theuppermost spinous processes of the thoracic spineand angles inferiorly to the superior medial angleof the scapula. The rhomboids originate from thespinous processes, are located inferior to the leva-tor scapula, and attach to the medial border of thescapula.

MANEUVER: The patient is asked to sit up. The muscles are palpated halfway between the spinousprocesses and the medial scapular border, begin-ning just above the level of the superior medial an-gle of the scapula and extending to the level of theinferior angle.

ASSOCIATED SIGNS: None.

INTERPRETATION: Irritation and spasm of the levatorscapula and rhomboid muscles are the most com-mon cause of interscapular pain and result fromany of the causes of dorsokyphotic posture (e.g.,aging, compression fracture, scoliosis).

FIGURE 3–10. Palpation of the levator scapula and rhomboidmuscles.

PALPATION OF THE TRAPEZIUS MUSCLE

SUMMARY: The trapezius muscle is divided into su-perior, middle, and lower thirds. The muscle origi-nates from the spinous processes and inserts on thedistal acromion process.

MANEUVER: Focal tenderness of the trapezius mus-cle usually is located halfway between the base ofthe neck and its attachment to the distal acromion.Firm pressure is applied at this site to determine thedegree of muscular spasm and tenderness.

ASSOCIATED SIGNS: Passive ipsilateral rotation andcontralateral bending of the neck place the trapez-ius under tension, aggravating the muscle spasm.Local tenderness involving the middle and lowerthirds occurs with severe or chronic involvement.

INTERPRETATION: Acute trapezial spasm (intense local tenderness and moderate spasm) is seen with acute emotional or physical stress, cervicalstrain and radiculopathy, whiplash, and acute rota-tor cuff tendonitis. Chronic symptoms (mild tender-ness and rock-hard muscular spasm) are character-istic of fibromyalgia, age-related dorsokyphoticposture, and chronic cervical radiculopathy.

FIGURE 3–9. Palpation of the trapezius muscle.



SUMMARY: Local anesthetic block is used to identifythe muscle as a source of the upper back pain, ruleout referred pain from the cervical spine, and ruleout referred pain from the chest or abdomen.

POSITIONING: Sitting, relaxed shoulder.

SURFACE ANATOMY: Lateral edge of the acromion,the spinous processes, and the spine of thescapula.

POINT OF ENTRY: Halfway between the distalacromion and the spinous processes.



DEPTH: 1⁄2 to 1 inch to the fascia and 1⁄4 inch intothe muscle.

ANESTHESIA: Ethyl chloride, skin: 1 mL at the der-mal/fascia, 1 to 2 mL intramuscularly.

FIGURE 3–11. Local anesthetic block placed in the superiordivision of the trapezius muscle.


SUMMARY: Local anesthetic block is used to identifythe muscle as a source of the upper back pain, ruleout referred pain from the cervical spine, and ruleout referred pain from the chest or abdomen.

POSITIONING: Sitting, relaxed shoulder.

SURFACE ANATOMY: The spinous processes andthe medial border of the scapula.

POINT OF ENTRY: Halfway between the spinousprocesses and the medial border of the scapula.



DEPTH: 1⁄2 to 1 inch to the fascia and 1⁄4 inch intothe muscle.

ANESTHESIA: Ethyl chloride, skin: 1 mL at the dermal–fascial interface, 1 to 2 mL intramuscularly.

FIGURE 3–12. Local anesthetic block placed in the rhom-boid major muscle.

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SUMMARY: Local anesthetic block is used to identifythe subscapular bursa as the source of the upperback pain (as opposed to the trapezial or levatorscapulae muscles), rule out referred pain from thecervical spine, and rule out referred pain from thechest or abdomen.

POSITIONING: Sitting, relaxed shoulder, the ipsilat-eral hand placed on the contralateral shoulder.

SURFACE ANATOMY: The underlying ribs and thesuperior medial angle of the scapula.

POINT OF ENTRY: Directly over the rib that is clos-est to the superior medial border of the scapula.



DEPTH: 1⁄2 to 1 inch down to the periosteum of therib.

ANESTHESIA: Ethyl chloride, skin: 1 to 2 mL at thelevel of the periosteum of the rib.

FIGURE 3–14. Local anesthetic block placed in the sub-scapular bursa.


OBJECTIVE: The scapula makes its closest contact with the underlying ribs at its superior medial angle.Exaggerated movement of the scapula (chronic shoul-der conditions and C5 radiculopathy affecting the rotator cuff muscles) increases friction between thescapula and the ribs (subscapular bursitis). The sub-scapularis muscle originates from the undersurface of scapula and acts as a natural protective pad.

MANEUVER: The superior medial angle of thescapula is marked with a pen. The patient isasked to place the hand on the contralateral shoulder (full adduction exposes the bursa). The ribs closest to the angle of the scapula are palpated for focal tenderness.

INTERPRETATION: A half dollar–sized area of ten-derness at the superior medial angle must be distin-guished from upper back muscular strain and pri-mary involvement of the rib. If subscapular bursitisis diagnosed, it is necessary to identify the underly-ing cause, namely loss of the normal glenohumeraljoint motion or cervical radiculopathy at C5 affect-ing the integrity of the rotator cuff muscles.


SUBSCAPULAR BURSITIS Often overlooked because of itshidden location under the superior medial angle of the scapula,this friction point between the undersurface of the scapula and theunderlying ribs is easily diagnosed by local anesthetic placed just

over the adjacent rib. This focal inflammation usually results fromthe exaggerated shrugging that accompanies impaired mobility atthe glenohumeral joint.


SCOLIOSIS Midback pain is a common manifestation of scol-iosis involving the thoracolumbar spine. The paraspinal muscles

HEIGHT MEASUREMENT

SUMMARY: Scoliosis is defined as an S-shaped curva-ture of the spine over 10 to 15 degrees. All patientswith significant curvature experience recurrent musclespasm. Progressive increases in the angle of curva-ture cause increased muscular symptoms, progressivechest wall deformity, and gradual loss of height.

MANEUVER: Serial heights should be performed in bare feet, with the patient standing as straight as possible.

ADDITIONAL SIGNS: Paraspinal muscle spasm isnearly universal. If the curvature is associated with a rotational component, the paraspinal muscles onthe convex side of the curve will appear enlarged.The paraspinal muscle enlargement can be enhancedby flexion at the waist (the paraspinal hump sign).

INTERPRETATION: Serial loss of height is seen withnormal aging, degenerative arthritis, compressionfracture, and scoliosis. A decrease in height of 1⁄2inch over a 6- to 12-month period suggests that thepatient’s spinal disorder is progressing. Patientswith structural conditions affecting the spine, espe-cially scoliosis, should undergo repeat standingradiographs if height continues to decrease.

FIGURE 3–15. Height measurement to evaluate the progres-sion of scoliosis.

ANTEROPOSTERIOR SPINE X-RAY

CASE: The patient has a family history of curvatureof the back. She suffers episodes of middle and upper back pain that typically resolves slowly overseveral weeks. She describes her pain as a tighten-ing of the back muscles.

DIAGNOSIS: Congenitally acquired scoliosis withreactive muscle spasm.

DISCUSSION: Muscular symptoms are the mostcommon manifestation of scoliosis. The paraspinalmuscles along the convex side of the curve are be-ing stretched while the muscles on the concave sideare foreshortened and susceptible to contracture.

The curve is measured by extending parallel linesfrom the most involved vertebra, dropping perpen-dicular lines down to an intersection point, and using a protractor to determine the angle. After a baseline level is obtained at the time of pres-entation, a second measurement should be ob-tained at 1 year to see whether the process is stable or progressive. Repeat measurements are indicated if the patient’s height has decreased by1⁄2 inch over the course of 6 to 12 months.

FIGURE 3–16. Anteroposterior spine x-ray for measure-ment of the scoliosis curvature.

are under constant tension, stretched beyond their normal lengthalong the convexity of the curve.

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RIB CONTUSION AND FRACTURE Rib contusions or frac-tures involving the posterior ribs cause upper back pain. It is dra-matically aggravated by deep breathing, coughing, sneezing, anddirect pressure. The diagnosis is strongly suggested by focal tender-

ness over the affected ribs elicited by manual chest compressionfrom the anteroposterior direction or pressure applied obliquelyacross the thorax.


SUMMARY: The bony thorax consists of the sternum, the costal cartilages, the ribs, and the vertebral bodies.


ADDITIONAL SIGNS: With the patient in the decubi-tus position, pressure applied over the mid- to lowerthorax causes intense pain. Rib fracture associatedwith pneumothorax can produce subcutaneous em-physema (air dissecting into the soft tissues of thechest). Superficial bruising is variable.

INTERPRETATION: A positive chest compression testis seen with any significant injury to the thorax, in-cluding rib contusions, rib fracture, nondisplacedrib fracture, costochondritis, and sternal fracture.

FIGURE 3–17. Chest compression test to assess the integrityof the bony thorax.

RADIOGRAPH OF THE CHEST

CASE: This 55-year-old man fell 8 feet off a ladderand landed on concrete on his left side. There wasimmediate localized chest pain and local bruising.Because of a history of coronary artery diseasewith arrhythmia, the patient was admitted to thecoronary care unit for observation. The patientcomplained of persistent left lateral chest pain ag-gravated by deep breathing, lying on the left side,and coughing.

DIAGNOSIS: A displaced rib fracture is seen in the posterior aspect of the seventh rib. Serial chest x-rays looking for an accompanying pleural effu-sion (hemothorax) were negative.

DISCUSSION: Because of the thinness of the boneand the overlying tissues, nondisplaced rib fractures(cracks) are difficult to identify on plain chest x-rays. Serial chest x-rays or special tangential ribviews may disclose a fracture only when the frac-ture begins to heal (the osteoblastic phase).

FIGURE 3–18. Chest x-ray demonstrating rib fracture.


VERTEBRAL BONY LESIONS Compression fractures due toosteoporosis are common in the lower thoracic and lumbar spineand uncommon in the upper thoracic spine. Fractures affecting the

T6–T1 vertebral bodies should be considered pathologic (metasta-tic or septic) until proven otherwise.

INTERCOSTAL NERVE BLOCK FOR RIB FRACTURE

SUMMARY: Local anesthetic block is used to reducethe intense pain in patients with acute rib fracture,to palliate the pain of bony metastases, and as alocal anesthetic block to determine the origin of thepatient’s pain, thus helping to distinguish rib painfrom soft tissue involvement.

POSITIONING: Sitting or lying down.

SURFACE ANATOMY: Superior and inferior edgesof the rib, the intercostal space, and the muscle.

POINT OF ENTRY: Just below the inferior edge of the rib on the proximal side of the fracture (i.e., between the fracture site and the spine).



DEPTH: 1⁄2 to 3⁄4 inch to the rib and 1⁄4 inch further to the underside of the rib.

ANESTHESIA: Ethyl chloride, skin: 1 mL at edge of the rib and 1 to 2 mL underneath the rib.

FIGURE 3–19. Intercostal nerve block for rib fracture.

PALPATION OF THE SPINOUS PROCESSES

SUMMARY: Patients with osteoporosis, known malig-nancy, or recent trauma are at the greatest risk ofdirect involvement of the vertebral body. Each indi-vidual spinous process must be palpated if the pa-tient describes midline back pain.

MANEUVER: Each spinous process is palpated withthe index finger. This is followed by gentle fist per-cussion of each vertebral level if tenderness is notelicited by palpation.

ADDITIONAL SIGNS: Percussion over the vertebralbody may cause pain wrapping around the chestwall (radicular pain). Loss of sensation in a thoracicdermatome is seen with advanced vertebral bodylesions.

INTERPRETATION: Primary involvement of the verte-bral bodies is not common. Acute compression frac-tures occurring between thoracic level T12 and T7are most commonly due to osteoporosis or blunttrauma. Compression fractures occurring above tho-racic level T6 must be considered pathologic (due tomalignancy) until proven otherwise. Shingles shouldbe considered if the patient experiences dramaticradicular pain wrapping around the chest wall ac-companied by minimal vertebral bony tenderness.

FIGURE 3–20. Palpation of the spinous processes to assessvertebral bony tenderness.

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NUCLEAR BONE SCAN

CASE: This patient fell from a ladder. He landed ina partially reclined position, striking his buttocks.Pain and acute muscle spasm developed immedi-ately. Physical examination demonstrated intensemuscle spasm, local tenderness over the spinousprocess of L1, and tenderness of the paraspinalmuscles.

DIAGNOSIS: Compression fracture of L1 with increased uptake on bone scan.

DISCUSSION: The asymmetrical collapse of a verte-bral body coupled with the intense paraspinal mus-cle spasm can cause an acquired scoliosis (as seenin this case).

FIGURE 3–21. Nuclear bone scan demonstrating bony activ-ity from an acute compression fracture.

MRI

CASE: This industrial worker fell 20 feet, landing onhis buttocks. Acute pain in the midback was fol-lowed by intense muscle spasm. In the days that fol-lowed, he suffered lancinating pain that wrappedaround the chest wall and took his breath away.

DIAGNOSIS: Lateral views of the thoracic spinedemonstrate a fragmented T6 compression fractureleading to an exaggerated kyphosis (gibbus). Chestx-ray revealed no intrinsic lung or cardiac disease.

DISCUSSION: Most compression fractures healgradually over a period of 4 to 8 weeks. Few war-rant surgical intervention. Indications for surgical referral include associated neurologic symptoms, instability, and persistent symptoms. With instabilityand nerve compression, stabilization is the proce-dure of choice.

FIGURE 3–22. MRI demonstrating a fragmented compressionfracture.


REFERRED PAIN FROM CERVICAL RADICULOPATHYEach of the lower cervical roots (C6–C8) refers pain over thescapula. The diagnosis of referred pain can be very difficult, espe-

cially when the symptoms of paresthesias or hypesthesias in the up-per extremity are not prominent. The diagnosis should be suspectedif the upper back pain is not accompanied by focal tenderness.

REFERRED UPPER BACK PAIN

SUMMARY: Each of the lower three cervical rootscan refer pain over the upper back and the scapulain particular. The pain is characteristically intensebut unassociated with local tenderness. The diagno-sis of cervical radiculopathy often is not consideredbecause of the conspicuous absence of the typicalassociated paresthesias or hypesthesias of the up-per extremity.

MANEUVER: Full examination of the neck and up-per extremity neurological exam are performed.

ADDITIONAL SIGNS: Although there may be signsof muscular strain (trapezius and rhomboid mus-cles), the area of intense pain is not particularly ten-der (over the body of the scapula). The patient’spain is most aggravated by the typical movementof the neck in rotation and lateral bending.

INTERPRETATION: This limited form of sensory cervi-cal radiculopathy has a good prognosis. No motorinvolvement is present, making aggressive treatmentrarely necessary.

FIGURE 3–23. The patient describes pain around the scapulaand shoulder but has no tenderness.

OBLIQUE VIEW OF THE CERVICAL SPINE

CASE: This 57-year-old man had a severe motor vehicle accident 20 years before presentation. Hesustained a concussion and severe whiplash at thetime. Over the last several years he has com-plained of intermittent stiffness of the neck and mostrecently of pain in the upper back. Examination dis-closed limited rotation to 70 degrees, pain aggra-vated by downward compression of the head(Spurling maneuver), and partial pain relief withmanual vertical traction on the neck. Neurologicexam of the upper extremities was normal.

DIAGNOSIS: The oblique views of the neck demon-strate a reversed curvature of the neck, foraminalnarrowing at multiple levels, and a dumbbell-shapednarrowing at the C6–C7 interspace (the seventh cer-vical root, named for the lower vertebra).

DISCUSSION: The most common cause of cervicalradiculopathy is foraminal encroachment by osteo-phytes from the paravertebral joints of Luschka andfacet joints. Osteophytes project into the foramen,causing the dumbbell-shaped foraminal narrowing.Because the nerve is approximately 1⁄3 the size ofthe opening, a 50% narrowing of the normalforaminal shape can lead to radicular symptomsand signs.FIGURE 3–24. Oblique view of the cervical spine demon-

strating the dumbbell-shaped foraminal encroachment causingradiculopathy.


EXAMINATION MANEUVERS DIAGNOSIS CONFIRMATION PROCEDURES

Local tenderness of the trapezius, levator 1. Upper back muscle Local anesthetic placed into the involved muscle (optional)scapulae, or rhomboid muscles strain, fibromyalgia

Focal tenderness at the superior medial angle Subscapular bursitis Local anesthetic placed in the bursaof the scapula (the arm fully adducted)

Measure the patient’s height Scoliosis Chest x-ray for screening or a full-length anteroposterior spine to assess and measure the thoracic curves

Abnormal thoracic kyphosis

Paraspinal muscle spasm or paraspinal muscle hump

Abnormal chest compression Rib fracture, intercostal Local anesthetic placed over the intercostal nerve (optional) muscle spasm, or chest x-rayankylosing spondylitis

Less than 21⁄2-inch chest expansion

Local tenderness of the spinous process Compression fracture, Chest x-ray, MRIvertebral body bony lesion, epidural process

Percussion tenderness

Muscle spasm

UPPER BACK 65

• Muscle strain and spasm of the upper back muscles arethe dominant conditions of the upper back. Chronicmuscular symptoms affecting the upper back result fromchronic stress, chronic poor posture, fibromyalgia, thedorsokyphotic changes of aging, or scoliosis.

• Most cases of upper back muscular strain are benign.However, an underlying thoracic nerve or thoracic ver-tebral body lesion must be considered when the reactivemuscular spasm is acute and severe or progressive or theresponse to treatment is poor.

• Symptoms of upper back pain associated with cautiousmovement, general stiffness, and restricted movementof the neck should suggest the early presentation of asensory radiculopathy arising from irritation of one ofthe lower cervical spinal nerves.

• Patients with a history of lung, breast, or prostate can-cer who present with focal tenderness in the scapular or

CLINICAL PEARLS

rib areas must undergo bone scanning or MRI to ruleout metastatic involvement of the bone. Alternatively,if physical examination suggests a focal musculoskeletalprocess, local anesthetic block can be considered toconfirm the exact anatomic location of their pain.

• Periscapular pain that is associated with local tender-ness arises in the supporting muscles of the upper backor in the subscapular bursa. Periscapular pain thatlacks local tenderness usually arises from the cervicalspine, referred from one of the lower cervical roots(C6, C7, or C8).

• Osteoporosis occurring in the postmenopausal period isthe most common cause of compression fracture. Thesefractures typically occur between vertebral levels T7 andL5. Any compression fracture above T7 should be con-sidered pathologic (e.g., metastatic disease, tuberculous)until proven otherwise.

66

CHAPTER 4: ELBOW


Diagnoses

Lateral epicondylitis (most common)

Brachioradialis muscle strain

Medial epicondylitis

Olecranon bursitisDraftsman’s elbowSeptic bursitisBursitis secondary to goutHemorrhagic bursitis secondary to chronic

renal failure

Olecranon spur fracture

Triceps tendonitis

Radiohumeral arthritisOsteochondritis dissecans

Posttraumatic osteoarthritisInflammatory arthritisHemarthrosis

Cubital tunnel

Bicipital tendonitis

Referred painCervical spineCarpal tunnel syndromeShoulder tendonitis

Confirmations


Examination


Aspiration, hematocritAspiration, Gram stain and cultureAspiration, crystal analysisAspiration, hematocrit, chemistries

X-ray: elbow series

Examination

X-rays, magnetic resonance imaging (MRI), surgicalexploration

X-ray: elbow seriesAspiration, cell countAspiration, hematocrit

Nerve conduction velocity testing


Neck rotation, x-ray, MRINerve conduction velocity testingPainful arc, subacromial tenderness, isometric testing

of the tendons

ELBOW 67

INTRODUCTION Arriving at a specific diagnosis at theelbow is straightforward because lateral epicondylitis, ole-cranon bursitis, and medial epicondylitis represent morethan 90% of the diagnoses. The pragmatic approach to thedifferential diagnosis emphasizes range of motion testing ofthe two compartments of the elbow joint to excludearthritic involvement followed by specific testing for thecommon three conditions. Examining the elbow in this se-quence allows the provider to rapidly arrive at the correct diagnosis.

Lateral epicondylitis (tennis elbow) represents 70% ofthe diagnoses at the elbow. The quarter-sized attachmentof the extensor carpi radialis tendons at the lateral epi-condylar process of the distal humerus is susceptible totension and traction when performing repetitious func-tions such as lifting, pushing, or pounding. In tennis theclassic injury results from the single-grip backhand volley.The force of impact and the tension generated by all ofthese actions travel back from the wrist to the origin of thetendon at the lateral epicondyle. Pathologically, the ten-don has been disrupted from its bony attachment on a microscopic level (microsplitting, microtearing, and mi-croavulsion). Lateral epicondylitis is the quintessentialtype of mechanical tendon injury.

Medial epicondylitis (golfer’s elbow) is one tenth as com-mon as lateral epicondylitis. It is nearly identical to lateralepicondylitis in pathology, pathophysiology, examination,and treatment. As with lateral epicondylitis, successful treat-ment depends on the body’s ability to form a strong reat-tachment of the tendon to the periosteum of the elbow.Incomplete healing (poor reattachment) leads to recurrentepisodes of tendonitis.

Olecranon bursitis (draftsman’s elbow) is the third mostcommon condition at the elbow. The olecranon is uniqueamong the 200 bursae of the body in that it is susceptible toinfection with Staphylococcus aureus and the deposition ofuric acid with acute gout. However, the majority of cases arecaused by repeated episodes of direct pressure over the el-bow (traumatic bursitis). And because acute traumatic bur-sitis can appear just as inflamed as septic or gouty bursitis,it is imperative that every bursa undergo diagnostic aspira-tion and laboratory analysis of the fluid.

Involvement of the elbow joint is uncommon. Post-traumatic osteoarthritis (e.g., trauma, osteochondritis disse-cans, prior fracture) and rheumatoid arthritis are the twomost common underlying causes. The diagnosis is alwayssuspected if the patient has lost a significant degree of rangeof motion in extension or flexion.

Fractures in adults are uncommon. Falls onto an out-stretched arm lead to injures at the wrist and shoulder moreoften than at the elbow. Falls directly onto the olecranon orsevere hyperextension injuries can lead to fractures of theulna, fracture or dislocation of the radial head, or fracture ordislocation of the ulnar articulation with the humerus.

Finally, pain can be referred to the elbow from the shoul-der, cervical spine, or heart or may travel through the elbow,

as in carpal tunnel syndrome and cervical radiculopathy. Aswith any referred pain, the range of motion of the elbow ismaintained, and the anatomic structures surrounding thejoint are free of local tenderness.

SYMPTOMS Conditions directly affecting the elbowcause pain (epicondylitis), swelling (olecranon bursitis), or aloss of range of motion (radiocarpal joint).

Lateral elbow pain is the most common complaint andarises from the lateral epicondyle or radiohumeral joint oris referred from the shoulder or neck. The pain of lateralepicondylitis typically is well localized (the patient oftenpoints to the lateral epicondylar process) and is aggra-vated by lifting or repetitious use of the forearm and wrist.Pain arising from the elbow joint is located slightly moreposteriorly to the epicondyle (between the epicondyleand the olecranon process). It is not as well localized asthe pain from the epicondyle and is readily distinguishedby its effect on the range of motion of the elbow (lateralepicondylitis rarely affects the range of motion of thejoint). Lateral elbow pain that is referred to the elbow issuggested by its vague localization and description, itslack of effect on elbow movement, its lack of local ten-derness, and its more direct relationship to the movementof the shoulder or neck.

Medial elbow pain is the second most common com-plaint and arises from the medial epicondyle, the ulnarnerve as it travels through the cubital tunnel, or rarely fromthe radiohumeral joint. As with lateral epicondylitis, thepain of medial epicondylitis is well localized and is aggra-vated by lifting or repetitious use of the forearm and wrist.The pain arising from the ulnar nerve is suggested by its ra-diation into the ulnar side of the hand and the associated af-fects on sensation in the fourth and fifth fingers.

Posterior elbow swelling is the classic complaint of ole-cranon bursitis. The rapidity in which the warmth, red-ness, and swelling develop provides the most importantclue to the underlying cause. Traumatic bursitis swellsgradually and is mildly red and warm. By contrast, theswelling of septic and gouty bursitis develops rapidly, andthe overlying soft tissues are dramatically inflamed, typi-cally red and hot.

Lateral elbow swelling is characteristic of a primary in-volvement of the joint. However, these symptoms arenearly always overshadowed by the universal complaint, “Icannot straighten my elbow.” Small effusions, whether dueto trauma, osteochondritis dissecans, rheumatoid arthritis,or posttraumatic arthritis, cause an immediate loss of ex-tension. Moderate to large effusions impair both extensionand flexion.

Finally, baseball players and gymnasts describe a loss ofsmooth motion of the elbow. This unique symptom is seennearly exclusively in throwers, vaulters, and floor exercisegymnasts and is the strongest clue to osteochondritis disse-cans of the humerus.


EXAMINATION The examination of the elbow beginswith an evaluation of the range of motion of the two com-ponents of the elbow joint (radiohumeral and ul-narhumeral) followed by an evaluation of the epicondylesand olecranon bursa for local tenderness and swelling.Arthritis, joint effusion, and hemarthrosis involving the el-bow are uncommon (except with rheumatoid arthritis ortrauma). These are readily excluded by a normal range ofmotion in extension, flexion, supination, and pronation.The lateral and medial epicondyles are palpated to deter-mine the degree of forearm extensor or flexor tendonitis, re-

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL ELBOW FUNCTION ANDDIFFERENTIAL DIAGNOSIS

The next five maneuvers represent the minimal examinationof the patient presenting with elbow symptoms. Range ofmotion measurement and screening maneuvers for epi-condylitis and olecranon bursitis provide enough informa-tion to triage to x-ray, order appropriate labs, suggest generaltreatment recommendations, or proceed to more detailedexamination and treatment.

Lateral pain Lateral epicondylitisBrachioradialis strainRadiohumeral arthritis

Inflammatory arthritisPosttraumatic osteoarthritisOsteochondritis dissecansHemarthrosis

Medial pain Medial epicondylitisCubital tunnel

Posterior pain Olecranon bursitisTriceps tendonitis

Anterior pain Biceps insertionitisReferred pain Cervical radiculopathy

Carpal tunnel syndromeRotator cuff tendonitis

DIFFERENTIAL DIAGNOSIS OF ELBOW PAIN BASED ON ANATOMIC AREA

BOX 4-1

1. Perform range of motion testing of the elbow joint(flexion, extension, pronation, and supination).

2. Palpate the extensor tendons at the lateral epi-condyle and the flexor tendons at the medial epicondyle.

3. Inspect and palpate the olecranon bursa for swellingand chronic thickening.

4. Examine the neck, shoulder, and wrist for possiblereferred pain.

ESSENTIAL EXAMINATION OF THE ELBOWBOX 4-2

PASSIVE RANGE OF MOTION TESTING IN EXTENSION AND FLEXION

SUMMARY: Arthritic involvement or acute effusion of the ulnarhumeral articulation causes loss ofrange of motion, initially extension followed by flexion. Conversely, full range of motion essentiallyrules out an active involvement of the joint.

MANEUVER: Full arm extension and flexion arecompared side to side. Loss of smooth motion(ratcheting, popping, or dramatic crepitation) suggests osteochondritis or loose body.

INTERPRETATION: The loss of full extension withendpoint stiffness suggests a small effusion or mildarthritis. The loss of full extension and flexion withendpoint stiffness suggests either an acute, large effusion or moderate to severe arthritis.

FIGURE 4–1. Passive range of motion testing in extensionand flexion of the ulnarhumeral joint.

spectively. Involvement of the olecranon bursa is assessedby inspection and direct palpation of the olecranon bursa.If these four anatomic areas are normal, the neck, shoulder,and wrist should be examined to determine a referral sourceof elbow pain.

ELBOW 69

PASSIVE RANGE OF MOTION TESTING IN SUPINATION AND PRONATION

SUMMARY: Injury or arthritis affecting the radialhead causes a loss of smooth supination andpronation of the forearm.

MANEUVER: Passive supination and pronation arecompared side to side while palpating the radialhead, located 1 cm distal to the lateral epicondyle.The radial head is tender to direct pressure andmay exhibit popping or crepitation with passivemotion.

INTERPRETATION: The loss of full supination orpronation indicates previous fracture, dislocation of the elbow, or osteochondritis dissecans.

FIGURE 4–2. Passive range of motion testing in supinationand pronation of the radiohumeral joint.

LATERAL EPICONDYLAR TENDERNESS

SUMMARY: All cases of lateral epicondylitis arecharacterized and require the demonstration of local tenderness directly over the epicondylarprocess.

MANEUVER: With the elbow flexed at 90 degrees,the lateral epicondyle is readily identified and pal-pated for local tenderness. Swelling over the epi-condyle is uncommon.

INTERPRETATION: Local tenderness over the lateralepicondyle must be distinguished from the local joint line tenderness located between the lateralepicondyle, the radial head, and the olecranonprocess indicative of ulnarhumeral joint arthritis or effusion and the local tenderness of a bony fracture.FIGURE 4–3. Lateral epicondylar tenderness to screen for

lateral epicondylitis.

MEDIAL EPICONDYLAR TENDERNESS

SUMMARY: All cases of medial epicondylitis arecharacterized by local tenderness located 1⁄2 to 1 cm distal to the epicondylar process, directly over the tendon.

MANEUVER: With the elbow flexed at 90 degrees,the common flexor tendons are readily identifiedand palpated for point tenderness.

INTERPRETATION: Local tenderness over the com-mon flexor tendons alone virtually makes the diag-nosis of medial epicondylitis.

FIGURE 4–4. Medial epicondylar tenderness to screen formedial epicondylitis.



TRIAGE TO X-RAY For patients with a history oftrauma, risk of bony injury, possible joint involvement be-cause of loss of normal range of motion:

• Order three views of the elbow for patients with a historyof fall onto the forearm, crush injuries, or direct blow (ole-cranon or radial head fractures).

• Order three views of the elbow in patients with a loss offull range of motion (posttraumatic osteoarthritis,rheumatoid arthritis, or the arthritis accompanyingspondyloarthropathy).

• Order two views of the elbow for patients with recurrentolecranon pain (calcifications of the triceps tendon asso-ciated with triceps tendonitis or recurrent or chronic ole-cranon bursitis).

TRIAGE TO THE LAB For acute olecranon bursitis oracute septic arthritis:

• Order a complete blood cell count, uric acid, and erythro-cyte sedimentation rate for patients with acute olecranonbursal pain and swelling (traumatic, gouty, or septic bursitis).

• Order a complete blood cell count, uric acid, erythrocytesedimentation rate, and blood cultures for patients withacute pain, decreased range of motion of the joint, and in-flammatory changes laterally (hemarthrosis from traumaor inflammatory or septic arthritis of the elbow).

CONSIDER A BONE SCAN For patients with vaguebony pain and tenderness that does not correspond to thescreening examinations of classic epicondylitis, olecranonbursitis, or radiohumeral arthritis (bony fracture or lesion).

CONSIDER MRI For patients with incomplete or loss ofsmooth motion of the radiohumeral joint (osteochondritisdissecans).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate elbow pain and stiffness, unre-stricted movement of the joint, preserved forearm muscletone, and preserved gripping and grasping strength:

• Restrictions of lifting, gripping, grasping, and tooling (es-pecially tools requiring torque).

• Ice applied to the site of pain up to four times a day.• A pull-on neoprene elbow pad for bursitis or a forearm

compression brace for epicondylitis.• A full-strength nonsteroidal anti-inflammatory drug for 10

to 14 days.

DETAILED EXAMINATION: SPECIFIC ELBOWDIAGNOSES

A detailed examination of the elbow is necessary if the pa-tient has persistent or chronic symptoms, forearm muscle orhand strength is impaired, and the range of motion of theelbow is impaired.

INSPECTION AND PALPATION

SUMMARY: Swelling and variable degrees of inflammation characterize olecranon bursitis.

MANEUVER: With the elbow flexed at 90 degrees,the bursa is inspected for the swelling, inflamma-tion, and bursal wall thickening.

INTERPRETATION: Acute bursitis is characterized byballottable swelling and accompanying inflamma-tory changes of heat and redness. Chronic bursitiscaused by unremitting inflammation is also charac-terized by swelling, but in addition the bursal walltissues are palpably thickened.

FIGURE 4–5. Inspection and palpation of the olecranonbursa.

ELBOW 71

LATERAL EPICONDYLITIS A presumptive diagnosis of ten-nis elbow, the microtearing or microavulsion of the extensor carpiradialis brevis and longus tendons, is based on local tenderness di-rectly over the lateral epicondyle, pain aggravated by resisted wrist

extension and radial deviation, and normal range of motion ofthe elbow. During the examination emphasis is placed on the closemechanical relationship of the wrist and elbow.

PALPATION OF THE LATERAL EPICONDYLE

SUMMARY: Lateral epicondylitis is characterized by local tenderness directly over the epicondylarprocess.

MANEUVER: With the elbow flexed at 90 degrees,the lateral epicondyle is readily identified and pal-pated for localized tenderness.

ADDITIONAL SIGNS: Isometric resistance of wristextension (extensor carpi radialis longus and bre-vis), loss of grip strength, and pain aggravated bypassive supination and pronation are the additionalsigns of lateral epicondylitis.

INTERPRETATION: Mild lateral epicondylitis is char-acterized by local tenderness. Moderate involve-ment combines local tenderness with elbow pain reproduced by resisted wrist extension. Severe in-volvement is characterized by loss of grip strength.Local tenderness and pain aggravated by side-to-side compression of the proximal forearm muscula-ture suggests brachioradialis strain, a simpleoveruse of the muscle.

FIGURE 4–6. Palpation of the lateral epicondyle for lateral epi-condylitis.

LATERAL EPICONDYLITIS

SUMMARY: Local anesthetic placed at the interfaceof the subcutaneous fat and the outer fascia of thetendon is used to confirm the diagnosis and deter-mine the severity of the condition. Grip strengthmeasurement before and after local anesthesia isthe best prognostic indicator of a successful treat-ment outcome.

POSITIONING: Supine, elbow flexed to 90 de-grees, hand tucked under the buttock.

SURFACE ANATOMY: Lateral epicondyle, radialhead.

POINT OF ENTRY: Directly over the center of theepicondyle.

ANGLE OF ENTRY: Perpendicular if the patient has suf-ficient subcutaneous fat, 45-degree angle otherwise.


DEPTH: 1⁄4 to 5⁄8 inch.

ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL subcuta-neous, 1⁄2 mL at the tendon–fat interface.

FIGURE 4–7. Lateral epicondylitis confirmed by local anes-thetic block. NOTE: To avoid a painful injection, the anesthesia isplaced just outside the tendon, at the interface of the subcutaneousfat and the outer facia. If the needle is inserted at this properdepth, the needle should move back and forth when traction is applied to the skin.

MEDIAL EPICONDYLITIS

SUMMARY: Dramatic pain relief with local anes-thetic placed at the interface of the subcutaneousfat and the outer fascia of the flexor tendons or adramatic response to corticosteroid confirms the di-agnosis of epicondylitis. Grip strength measurementbefore and after local anesthesia is the best prog-nostic indicator of a successful treatment outcome.

POSITIONING: Supine, elbow flexed to 90 de-grees, 90 degrees of shoulder rotation.

SURFACE ANATOMY: Medial epicondyle, olecra-non process.

POINT OF ENTRY: 1⁄2 inch distal to the medial epicondyle.

ANGLE OF ENTRY: Perpendicular if there is suffi-cient subcutaneous fat.



ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL placed sub-cutaneously, 1⁄2 mL at the tendon–fat interface.


MEDIAL EPICONDYLITIS A presumptive diagnosis ofgolfer’s elbow, a microtearing or microavulsion of the flexor carpiradialis tendons, is based on local tenderness just distal to the me-dial epicondyle, pain aggravated by resisted wrist flexion and

radial deviation, and normal range of motion of the elbow.Medial epicondylitis is the mirror image of its lateral counterpart,although 90% less common.

MEDIAL EPICONDYLAR TENDERNESS

SUMMARY: Medial epicondylitis is characterized by local tenderness directly over the common flexortendons 1⁄2 to 1 inch distal to the epicondyle. Thisdiffers from lateral epicondylitis, which is tender directly over its bony origin.

MANEUVER: With the elbow flexed at 90 degrees,the flexor tendons are palpated for tenderness.

ADDITIONAL SIGNS: Isometric resistance of wristflexion (flexor carpi radialis longus and brevis), lossof grip strength, and pain aggravated by passivesupination and pronation characterize the completeexam.

INTERPRETATION: Mild medial epicondylitis is char-acterized by local tenderness. Moderate involve-ment combines local tenderness with elbow pain reproduced by resisted wrist flexion. Severe involve-ment is characterized by loss of grip strength.FIGURE 4–8. Palpation of the medial epicondyle for me-

dial epicondylitis.

FIGURE 4–9. Medial epicondylitis confirmed by local anes-thetic block. NOTE: To avoid a painful injection, the anesthesia isplaced just outside the tendon, at the interface of the subcutaneousfat and the outer facia. If the needle is inserted at this proper depth,the needle should move back and forth when traction is applied tothe skin.

ELBOW 73

OLECRANON BURSITIS The diagnosis of acute olecranonbursitis is readily made by noting the cystic swelling over the poste-rior olecranon process. However, bursal aspiration and lab analy-sis are necessary to distinguish the three common causes of bursalswelling: trauma (90%), sepsis (5%), or gout (5%).

Chronic olecranon bursitis is characterized by palpable thicken-ing to the bursal walls and variable degrees of cystic swelling.

INSPECTION AND PALPATION

SUMMARY: The olecranon bursa is palpated for lo-cal tenderness, cystic swelling, and chronic thicken-ing. The degree of acute inflammation and the ex-tent of surrounding erythema are noted.

MANEUVER: The optimal elbow position to evaluatethe olecranon bursa is at 90 degrees. The bursa ispalpated for ballottable fluid and bursal wall thick-ening. Any inflammatory changes are also noted.

ADDITIONAL SIGNS: The range of motion of the el-bow should be normal because the bursa is locatedextra-articularly.

INTERPRETATION: Acute bursitis is characterized byballottable swelling and accompanying inflamma-tory changes of heat and redness. Chronic bursitiscaused by unremitting inflammation is also charac-terized by swelling, but in addition the bursal walltissues are palpably thickened. Septic bursitis canbe accompanied by diffuse erythema and redness(i.e., cellulitis).

FIGURE 4–10. Inspection and palpation of the olecranonbursa.

NEEDLE ASPIRATION OF THE BURSA

SUMMARY: Aspiration of the bursa is necessary todistinguish the three major causes of acute bursitis:traumatic (predominantly blood), septic (purulentand positive culture), and gout (positive for crys-tals). If the patient has minimal ballottable swelling,the needle is advanced to the periosteum of theulna in the center of the bursa (the deep bursal wall is located at the level of the ulna).

POSITIONING: Supine, elbow flexed to 90 de-grees, forearm lying over the chest.

SURFACE ANATOMY: Olecranon process, lateralepicondyle.

POINT OF ENTRY: Distal, at the base of the bursa.

ANGLE OF ENTRY: Nearly parallel to the ulna.


DEPTH: Superficial, 3⁄8 to 5⁄8 inch.

ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL subcutaneous.

FIGURE 4–11. Olecranon bursitis confirmed by needle aspira-tion of the bursa.


TRICEPS INSERTIONITIS Triceps insertionitis is an uncom-mon condition. Patients performing repetitive pushing, too manypush-ups, or unaccustomed bench press exercises are at particularrisk. The diagnosis is characterized by focal tenderness over the

insertion on the posterior olecranon process and pain aggravatedby resisted elbow extension. A fractured olecranon spur is ex-cluded by plain x-rays, and olecranon bursitis is excluded byexam and aspiration.

FOCAL TENDERNESS

SUMMARY: All patients with triceps tendonitis havefocal tenderness on the posterior aspect of the ole-cranon process.

MANEUVER: The triceps insertion is palpated for lo-cal tenderness and swelling.

ADDITIONAL SIGNS: Isometric resistance of elbowextension reproduces the patient’s elbow pain. Therange of motion of the elbow should be normal.The olecranon bursa is not acutely inflamed.

INTERPRETATION: The focal tenderness of olecranonbursitis, triceps insertionitis, and fractured olecra-non spur overlap. Acute bursitis is characterized by ballottable swelling. Fractured olecranon spur is confirmed by x-ray. The diagnosis of triceps inser-tionitis is made by resisting elbow extension and by the exclusion of the other two diagnoses.

FIGURE 4–12. Focal tenderness of triceps insertionitis.

LATERAL X-RAY VIEW OF ELBOW

SUMMARY: Olecranon spurring occurs in the body of the triceps tendon. Most exostoses off the olecranon process are completely asymptomatic.The larger 1⁄2-cm spurs are susceptible to fracturecaused by a fall onto the elbow or direct blow.Focal tenderness with minimal swelling (none in the characteristic olecranon bursal area) is presenton the proximal olecranon process.

FIGURE 4–13. Olecranon spur fracture confirmed by lateral x-ray view of elbow.

ELBOW 75

ULNARHUMERAL (ELBOW) JOINT ARTHRITIS Arthritisof the elbow is uncommon. Most cases are the result of previoustrauma (intra-articular fracture), rheumatoid arthritis, or othersystemic rheumatologic conditions. The diagnosis should always

be considered if the range of motion of the elbow is impaired (extension is preferentially affected in the early case). Confirmationrequires joint aspiration or typical changes on x-ray.

PASSIVE RANGE OF MOTION

SUMMARY: Arthritic involvement or acute effusion of the ulnarhumeral articulation causes loss ofrange of motion; initially extension is impaired, followed by flexion.

MANEUVER: Full arm extension and flexion arecompared side to side.

ADDITIONAL SIGNS: Tenderness and swelling (thebulge sign) are located in the triangle formed bythe radial head, the olecranon process, and the lat-eral epicondyle. Loss of smooth motion (ratcheting,popping, or dramatic crepitation) suggests osteo-chondritis or loose body.

INTERPRETATION: The loss of full extension withendpoint stiffness suggests a small effusion or mildarthritis. The loss of full extension and flexion withendpoint stiffness suggests either an acute, large effusion or moderate to severe arthritis.

FIGURE 4–14. Passive range of motion testing of the ul-narhumeral joint.

LATERAL X-RAY VIEWS OF THE ELBOW

SUMMARY: This 48-year-old native Hawaiian hadan acute injury to his elbow 32 years before pre-senting to the clinic with elbow pain and impairedrange of motion. Every Saturday he delivered hisfather’s lunch to him on the job (his father drove thesugarcane train on the island of Maui). He alwaysclimbed a nearby palm tree to watch for the train’sarrival. At age 16 he fell from the tree, striking hiswhole weight on the right elbow. He did not seekmedical attention at that time. Over the last fewyears he has gradually developed lateral elbowpain and progressive loss of range of motion.

DIAGNOSIS: Osteoarthritis of the ulnarhumeral jointwith hypertrophic spurring and loss of joint space.

INTERPRETATION: The loss of full extension withendpoint stiffness suggests a small effusion or mildarthritis. The loss of full extension and flexion withendpoint stiffness suggests either an acute, large ef-fusion or moderate to severe arthritis.

FIGURE 4–15. Osteoarthritis of the ulnarhumeral joint confirmedby lateral x-ray views of the elbow.


RADIOGRAPHIC CHANGES OF RHEUMATOIDARTHRITIS

SUMMARY: This 62-year-old Swedish Americannurse developed polyarticular inflammatory smalljoint arthritis at age 32. Over the years involvementin the wrists, elbows, knees, ankles, and shouldershas developed. She presented with bilateral elboweffusions with painful, limited range of motion inher mid-fifties.

DIAGNOSIS: Rheumatoid arthritis of the elbow con-firmed by aspiration of an inflammatory effusion.The elbow has lost nearly all the articular cartilagein a symmetrical pattern. The bones demonstratediffuse osteopenia. Minimal reactive osteophytesare present.

DISCUSSION: Rheumatoid arthritis is characterizedby a symmetrical loss of articular cartilage, as op-posed to the typical asymmetrical loss of cartilagewith osteoarthritis.

FIGURE 4–16. Radiographic changes of rheumatoidarthritis involving the radiohumeral and ulnarhumeral joint.

ASPIRATION OF THE ELBOW JOINT

SUMMARY: Aspiration of the elbow joint is indi-cated to differentiate traumatic hemarthrosis frominflammatory arthritis and the rare case of septicarthritis.

POSITIONING: Supine, elbow flexed to 90 de-grees, hand tucked under the buttock.

SURFACE ANATOMY: Lateral epicondyle, radialhead, and the olecranon process.

POINT OF ENTRY: In the center of the inscribed triangle.

ANGLE OF ENTRY: Perpendicular to the skin andparallel to the radial head.

NEEDLE: 1 inch, 21 or 22 gauge.

DEPTH: 3⁄4 to 1 inch.

ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL subcuta-neously, 1⁄2 mL at 3⁄4 inches or adjacent to bone.

FIGURE 4–17. Aspiration of the elbow joint to determine thecause of the effusion.

ELBOW 77

BICEPS INSERTIONITIS Inflammation at the insertion of thebiceps on the radial tubercle is an uncommon problem. Repeatedlifting or an intense downward force on the arm causes microtear-

ing and secondary inflammation to develop at the attachment site.Patients describe a deep ache in the antecubital fossa that is aggra-vated by direct pressure and isometric flexion of the elbow.

LOCAL TENDERNESS OF THE INSERTION OF THE BICEPS

SUMMARY: The diagnosis of biceps insertionitis is difficult to make. The clinical signs overlap withthose of muscular strain of the forearm muscles,strain to the ulnarhumeral joint, and the conditionsthat refer pain through the elbow (shoulder ten-donitis, carpal tunnel, pronator teres syndrome, and cervical radiculopathy).

MANEUVER: With the elbow flexed at 90 degrees,the biceps tendon is identified in the antecubitalfossa and followed down to its attachment deep inthe forearm adjacent to the radial tubercle. Focaltenderness at this exact location suggests biceps insertionitis.

ADDITIONAL SIGNS: Isometric resistance of elbowflexion that reproduces the patient’s pain assists inthe diagnosis.

INTERPRETATION: The long head of the biceps ismuch more susceptible to injury and inflammationthan the combined distal biceps tendon.FIGURE 4–18. Local tenderness of the insertion of the

biceps in the antecubital fossa.

ISOMETRICALLY RESISTED ELBOW FLEXION

SUMMARY: The patient sustained a substantial in-jury and has felt a popping sensation in the antecu-bital fossa. Local tenderness is present along thedistal portion of the combined short and long headbiceps tendon. Resisting elbow flexion should repro-duce the pain of this uncommon injury.

MANEUVER: With the elbow flexed at 90 degrees,the examiner asks the patient to flex against resis-tance. Pain and weakness of flexion are noted.

ADDITIONAL SIGNS: The range of motion of the elbow should be normal. No evidence of primaryshoulder pathology, cervical radiculopathy, or median nerve compression from carpal tunnel or pronator teres syndrome should be present.

INTERPRETATION: Definitive diagnosis requires sur-gical exploration and repair. Surgical referral issuggested if the patient has lost 30% to 40% of hisor her strength on that side.

FIGURE 4–19. Isometrically resisted elbow flexion to re-produce the patient’s biceps pain.


CUBITAL TUNNEL SYNDROME Cubital tunnel syndrome isan entrapment neuropathy of the ulnar nerve as it courses throughthe bony channel of the proximal ulna. The diagnosis is suggestedby a description of hypoesthesias or paresthesia in the hand (thefifth finger and half of the fourth finger) or neuritic-like pain trav-

eling through the elbow and forearm. Examination of the elbowshould be normal except for a positive Tinel sign along the medialaspect of the proximal ulna, demonstrating ulnar nerve sensitivity.Unlike in carpal tunnel syndrome, muscular weakness is not a sig-nificant symptom of cubital tunnel syndrome.

TINEL SIGN FOR CUBITAL TUNNEL SYNDROME

SUMMARY: The cubital tunnel is formed betweenthe medial epicondyle and the olecranon process.The ulnar nerve lies in this bony groove. It providessensation to the fifth finger and lateral half of thefourth finger. Cubital tunnel is the most commoncause of ulnar neuropathy.

MANEUVER: With the elbow flexed at 90 degreesand the arm externally rotated, the medial epi-condyle and the olecranon process are identified.With firm pressure, the groove between the twobony prominences is tapped repeatedly with the tip of the finger.

ADDITIONAL SIGNS: The diagnosis of cubital tun-nel is much more likely if sensation in the fourthand fifth fingers is diminished; the abductor digitiminimi muscle is weak; the examination of the neck is normal, excluding the diagnosis of cervicalradiculopathy and brachial plexopathy; and the ex-amination of the wrist is normal, excluding entrap-ment of the ulnar nerve in the intercarpal area.

INTERPRETATION: A positive Tinel sign at the elbowshould reproduce the lancinating pain down theforearm or cause the paresthesias in the fourth andfifth fingers. The response should be distinctly differ-ent from that of the opposite side. Abnormal re-sponses should be confirmed with nerve conductionvelocity testing.

FIGURE 4–20. Tinel sign tapped over the cubital tunnel sug-gests ulnar neuropathy.

NERVE CONDUCTION VELOCITY TESTING

SUMMARY: The ulnar nerve function can be im-paired at the elbow (cubital tunnel), at the wrist,or anywhere along the course of the nerve fromtrauma (e.g., supracondylar fracture, crush injuriesof the wrist). A definitive diagnosis of cubital tun-nel requires the demonstration of nerve conductionslowing across the elbow. Simultaneous elec-tromyographic testing can be used to exclude significant lesions in the neck (brachial plexus lesions, thoracic outlet, or C8 radiculopathy).

FIGURE 4–21. Nerve conduction velocity testing to con-firm ulnar neuropathy.

4-1 DETAILED EXAMINATION SUMMARY

EXAMINATION SIGNS DIAGNOSIS CONFIRMATION PROCEDURES

Focal tenderness of the lateral epicondyle 1. Lateral epicondylitis Local anesthetic block at the lateral epicondyle (optional)

Pain reproduced by resisted wrist extension

Pain reproduced by resisted radial deviation of the wrist

Diminished grip strength

Focal tenderness of the medial epicondyle 2. Medial epicondylitis Local anesthetic block at the medial epicondyle (optional)

Pain reproduced by resisted wrist flexion

Pain reproduced by resisted radial deviation of the wrist

Diminished grip strength

Cystic swelling or thickening over the olecranon Olecranon bursitis Aspiration of the bursa for cell count, Gram stain,process and crystal analysis

Normal range of motion of the elbow joint

Tenderness of the triceps insertion on the ulna Triceps insertionitis Local anesthetic block over the tendon

Pain reproduced by resisted elbow extension

Full range of motion of the elbow

Loss of full elbow extension Radiohumeral arthritis Aspiration of the joint from the lateral approach

Lateral bulge sign halfway between the lateral epicondyle and the olecranon process

Loss of full flexion

Loss of supination or pronation

Antecubital fossa tenderness Bicipital insertionitis Examination


History of ulnar hypesthesia and paresthesia Cubital tunnel Nerve conduction velocity testing

�Tinel sign at the elbow

Normal neck exam (i.e., no evidence of C8 radiculopathy)

Pain through the elbow Referred pain from the Screening neck exam, screening shoulder exam, testing for neck, shoulder, or carpal tunnel syndromecarpal tunnel syndrome

Normal range of motion of the elbow

No focal epicondylar tenderness

No olecranon swelling

ELBOW 79


COMMON ELBOW FRACTURES

SUMMARY

Fractures of the elbow are not common in adults.

RADIAL HEAD FRACTURE

SUMMARY: Displaced radial head fractures shouldbe referred to an orthopedic surgeon for radialhead excision.

Nondisplaced radial head fractures can be treatedmedically. The preferred management with a slingand range of motion exercises is a classic example of the application of early physical therapy. It canbe combined with aspiration of the hemarthrosisand intra-articular injection of local anesthetic to assist in early exercising. Note that associated in-juries to the medial collateral ligament, interosseusmembrane, and wrist should be excluded.

IMMOBILIZATION: A simple sling.

SURGICAL REFERRAL: Surgery is reserved for dis-placed fractures.

PROGNOSIS: Patients are at risk for late-onset osteoarthritis.

FIGURE 4–22. Radial head fracture.

ELBOW DISLOCATION

SUMMARY: Elbow dislocation occurs mostly in theyoung (10 to 20 years) and in older adults. The el-bow usually dislocates posteriorly. Neurovascularevaluation of the brachial artery, median nerve, andulnar nerve is mandatory before reduction. Closedreduction involves distraction with or without hyper-extension to unlock the olecranon, followed by ante-rior translation. Open reduction is rare.

REDUCTION: (1) The patient is to be in a prone posi-tion. (2) The arm is hung over the side of the exami-nation table with weight applied to the wrist or withtraction applied by the examiner. (3) With constanttraction, and as the olecranon is felt to slip distally, theelbow is gently flexed. (4) The range of motion of theelbow in flexion to 30 degrees and in supination andpronation is performed to ensure the stability of the re-duction. (5) A posterior splint is applied for 2 to 3weeks. (6) Gentle, passive range of motion exercisesare performed within 1 to 2 weeks to prevent contrac-ture. (7) With improving motion, isometric toning exer-cises of elbow flexion and extension are begun.

IMMOBILIZATION: A posterior splint is applied for2 to 3 weeks.

SURGICAL REFERRAL: Open reduction is rare.

PROGNOSIS: Good.

FIGURE 4–23. Elbow dislocation without concomitant fracture.

ELBOW 81

NONDISPLACED FRACTURES OF THE SHAFTSOF THE RADIUS AND ULNA

SUMMARY: Fixed immobilization in a long-arm cast(axilla to metacarpals) with a collar and cuff sus-pension at the proximal forearm is the treatment ofchoice for a nondisplaced fracture. Displaced frac-tures must be evaluated by an orthopedic surgeon.

IMMOBILIZATION: A long-arm cast (axilla tometacarpals) with a collar and cuff suspension atthe proximal forearm.

SURGICAL REFERRAL: Displaced fractures requireopen reduction and fixation in order to counteractthe opposing muscular forces, restore the properlength of the bones, and achieve axial and rota-tional alignment. Similarly, open reduction and internal fixation is the preferred treatment for aMonteggia fracture in an adult (displaced fractureof the ulna with radial head dislocation).

PROGNOSIS: Good to excellent.FIGURE 4–24. Nondisplaced fractures of the shafts ofthe radius and ulna.

DISTAL HUMERAL FRACTURES: INTERCONDYLAR FRACTURE

SUMMARY: Intercondylar fractures should be re-ferred immediately to an orthopedic surgeon. The T- or Y-configuration fractures of the distal humerusare the most difficult to manage of fractures of theupper extremity. Open reduction with rigid internalfixation is the preferred treatment to optimize thealignment and continuity of the articular surfaces of the elbow.

FIGURE 4–25. Distal humeral fractures: intercondylarfracture.

• Normal range of motion testing of the elbow rules outinvolvement of the joint.

• Medial epicondylitis is a traction injury of the flexorcarpi radialis tendon, occurring within 1 cm of the mid-point of the medial epicondyle. Local tenderness is thehallmark of medial epicondylitis.

• Lateral epicondylitis is a traction injury of the extensorcarpi radialis tendon occurring at the midpoint of the

CLINICAL PEARLS

lateral epicondyle. Local tenderness is the hallmark oflateral epicondylitis.

• Epicondylitis and olecranon bursitis rarely affect therange of motion of the elbow. The only exceptions tothis rule are cellulitis accompanying a septic olecranonbursitis and chronic lateral epicondylitis in the patientwith an extremely low pain threshold.

82

CHAPTER 5: WRIST


Diagnoses

The continuum of injuries at the wristSimple wrist sprain (ligamentous)Sprain with chondral fracture

Navicular fracture

Perilunate dislocationKienböck’s disease

Triangular cartilage fracture of the ulnocarpal joint

Radiocarpal arthritisPosttraumatic osteoarthritisRheumatoid arthritis

Gout or pseudogout

Dorsal ganglionFrom the radiocarpal jointFrom the tenosynovial sheath

TendonitisDorsotenosynovitis

De Quervain’s tenosynovitis

Referred pain to the wristCarpometacarpal osteoarthritisCervical spineCarpal tunnel syndrome (CTS)

Pronator teres syndrome (mimicking CTS)

Confirmations

Examination, normal x-raysPersistent loss of grip, decreased range of motion,

and persistent tendernessLoss of 45% of the range of motion, sequential

x-rays, positive bone scanLoss of the normal bony alignmentA vascular necrosis of the lunate on serial x-rays

of the wristMagnetic resonance imaging (MRI) or arthroscopy

X-ray: wrist seriesSynovial fluid analysis, erythrocyte sedimentation

rate, rheumatoid factor (RF)Crystal analysis

AspirationAspiration

Examination, associated signs of rheumatoid arthritis,gout, or gonorrhea


X-rays: thumb seriesNeck rotation, x-ray, MRINerve conduction velocity testing or local anesthetic

blockNerve conduction velocity testing

WRIST 83

INTRODUCTION When approaching the differentialdiagnosis of wrist pain, the provider must first consider therole of injury. The joint is vulnerable to direct blows andto the twisting and compressive forces that result fromfalling onto an outstretched arm. This places tremendousstrain on the supporting ligaments, the delicate cartilage,and the bones that make up the joint. Depending on thenature of the injury, the differential diagnosis can be seenas a continuum of injuries. Simple wrist sprain, the mostcommon diagnosis, is a reversible stretching of the sup-porting ligaments. More substantial blows can cause frac-tures, cracks, and fissuring of the articular cartilage, orchondral fractures, a diagnosis that is often made only inretrospect when the apparent simple wrist sprain fails toimprove in the typical 2- to 3-week interval. Greater twist-ing and compressive forces can cause rupture of the sup-porting ligaments. The perilunate dislocation is the mostcommon example of ligament rupture. Rupture of the spe-cialized triangular cartilage located between the ulnar sty-loid and the triquetrum occurs on the ulnar side of thewrist. The most dramatic torque and compression forcescause bony fractures. Navicular fracture, avascular necrosisof the navicular, and Kienböck’s avascular necrosis of thelunate occur on the carpal side of the joint. Distal radiusfractures, including the most common form (Colles frac-ture), occur on the proximal side of the joint. The chal-lenge that faces the primary care provider is to determinewhere to place the individual patient on the continuum ofwrist injuries based on the type of injury, the effect on therange of motion of the joint, and the location of the pa-tient’s pain.

Despite the varieties of injuries that affect the wrist, direct involvement of the radiocarpal or ulnocarpal joint is uncommon. Late-onset osteoarthritis is uncommon.Arthritic involvement of the wrist is much more likely to becaused by a well-established rheumatic condition, such asrheumatoid or psoriatic arthritis, or a crystal deposition dis-ease such as gout or pseudogout. However, subtle damageto the joint is not without consequences. Moderate to se-vere ligament and cartilage injuries can cause an overpro-duction of synovial fluid. Over time this excessive fluid canleak into the subcutaneous tissue surrounding the joint.The highly viscous fluid incites a fibrotic reaction, causinga thick-walled encapsulated cyst to form. These are calledganglion cysts or synovial cysts, which are a manifestationof an injured wrist joint.

Tendonitis and tendon injuries are uncommon at thewrist as well. The diagnosis of dorsotenosynovitis, inflam-mation of the extensor tendons of the hand, is straightfor-ward because it usually occurs as a secondary manifesta-tion of rheumatoid arthritis, gout, or the systemic arthritis–dermatitis syndrome of gonorrhea. In addition, deQuervain’s tenosynovitis, an inflammation of the extensorand abductor tendons of the thumb, often is described as awrist pain, although strictly speaking it is not directly relatedanatomically to the wrist.

Pain referred solely to the wrist is uncommon. Medianneuropathy from pronator teres syndrome or carpal tun-nel can refer pain to the wrist, or pain can arise at the wristand travel in a retrograde fashion but rarely affects thewrist exclusively.

SYMPTOMS Conditions directly affecting the wristcause pain with movement (e.g., simple sprain, radiocarpalarthritis, distal radius fracture), swelling (localized [ganglioncyst] or diffuse [extensor tenosynovitis or reflex sympatheticdystrophy]), or changes in sensation aggravated by use ofthe wrist (carpal tunnel).

Dorsal wrist pain aggravated by flexion and extension isthe most common complaint and can arise from the liga-ments surrounding the joint, the synovium, the articularcartilage, or the bony structures of the radiocarpal joint. Ifthese symptoms follow an injury (a fall to an outstretchedarm or direct blow), the clinician must perform a compre-hensive examination and radiographic studies to distinguishinjury to the supporting ligaments (simple sprain and per-ilunate dislocation) from injuries affecting the articular car-tilage (chondral fracture) and bones (navicular and distal ra-dius fractures). If the symptoms are recurrent or chronic,radiographic studies and serologic testing are necessary todistinguish a rheumatic involvement of the joint from post-traumatic osteoarthritis.

Focal dorsal wrist swelling arises from the wrist joint.Painless dorsal wrist swelling is the characteristic of a gan-glion cyst. Note that a small number of patients experiencepain when the cyst places pressure on the adjacent tendonsor the superficial branch of the radial nerve. Painful dorsalwrist swelling over the navicular is characteristic of aswollen radiocarpal joint, although it may be too subtle tobe noticed in mild or moderate cases.

Diffuse dorsal wrist pain and swelling (extending fromthe wrist to the back of the hand) are much less common andis characteristic of extensor tenosynovitis, reflex sympatheticdystrophy (RSD), and metacarpal fractures. Involvement ofthe extensor tendons is likely if the pain is aggravated by

Dorsal pain Wrist sprainWrist sprain with chondral fractureNavicular fracturePerilunate dislocationKienböck’s diseaseRadiocarpal arthritis

Posttraumatic osteoarthritisRheumatoid arthritisGout and pseudogout

Dorsal ganglionDorsotenosynovitis

Radial pain CMC arthritis of the thumbDe Quervain’s tenosynovitisRadial collateral ligament strain

Lateral pain Lateral collateral ligament strainTriangular ligament strain

Volar pain Volar ganglionReferred pain CTS

Cervical radiculopathy

DIFFERENTIAL DIAGNOSIS OF WRIST PAIN BASED ON ANATOMIC AREA

BOX 5-1


movement of the fingers. RSD is characterized by vaguelydefined but severe pain that is not influenced by any par-ticular motion.

Paresthesia and hypesthesia aggravated by wrist move-ment or position are characteristic of carpal tunnel syn-drome (CTS).

Finally, some patients complain of wrist pain and weak-ness of the thumb or grip. Although strictly speaking thesepatients have a primary condition affecting the thumb (deQuervain’s tenosynovitis or arthritis at the base of thethumb), a significant percentage of these patients describetheir symptoms as arising from the wrist (see Chapter 6).

EXAMINATION The examination of the wrist beginswith the measurement of the range of motion of the ra-diocarpal joint in flexion and extension, the measurementor estimation of grip strength, and an estimation of thelooseness of the supporting ligaments. These functionaltests correlate directly with the severity of wrist sprain,fracture of the distal radius or carpal bones, and chronicarthritis. Involvement of the wrist joint is strongly sug-gested by local tenderness and swelling over the navicularand lunate bones. For patients complaining of pain acrossthe radial side of the wrist, specific maneuvers identifyingarthritis or tenosynovitis of the thumb must be performed.Approximately 25% of patients with carpometacarpal(CMC) arthritis or de Quervain’s tenosynovitis complainof wrist pain rather than thumb pain. Patients with diffuseswelling over the dorsum of the wrist and hand must be ex-amined for the presence of cellulitis, extensor tenosynovi-tis, or RSD.

ONE-MINUTE SCREENING EXAMINATION OF THE WRIST

The next eight maneuvers represent the minimal examina-tion of the patient presenting with wrist symptoms.Functional testing, range of motion measurement, andscreening maneuvers for dorsal swelling, conditions affect-ing the thumb, and carpal tunnel provide enough informa-tion to triage to x-ray, order appropriate labs, suggest generaltreatment recommendations, or proceed to more detailedexamination and treatment.

1. Evaluate the radiocarpal joint range of motion inflexion and extension and palpate the dorsum of thewrist for swelling.

2. Palpate the navicular and lunate bones, especially iftrauma has occurred.

3. Inspect the wrist for the presence of a ganglion cystover the dorsal wrist.

4. Perform the Tinel and Phelan maneuvers for CTS.5. Examine the base of the thumb for degenerative

arthritis or extensor tenosynovitis.

ESSENTIAL EXAMINATION OF THE WRISTBOX 5-2

RANGE OF MOTION AND ENDPOINT PAINAND STIFFNESS

SUMMARY: The distal radius, navicular, and lunatebones form the radiocarpal articulation. Ninety per-cent of the movement of the wrist occurs betweenthese three bones. The wrist is supported by a thinjoint capsule, a thick complex of criss-crossing liga-ments, and the fascia covering the flexor and exten-sor tendons, the retinaculum. Passive movement ofthe wrist in flexion and extension defines the in-volvement of the wrist (normal flexion averages 90degrees). The severity of the condition correlates directly with the loss of range of motion.

MANEUVER: The patient is asked to relax the mus-cles of the forearm. While the examiner holds thedistal forearm firmly, the wrist is passively flexed toits endpoint. Perform this cautiously in the acutelyinjured or inflamed wrist.

INTERPRETATION: See Figure 5-2 Interpretation.

FIGURE 5–1. Measure the range of motion of the wrist jointand assess endpoint pain and stiffness in flexion (volarflexion).

WRIST 85

RANGE OF MOTION AND ENDPOINT PAINAND STIFFNESS

SUMMARY: Passive movement of the wrist in flexionand extension defines the involvement of the wrist(normal extension averages 80 degrees). The sever-ity of the condition correlates directly with the lossof range of motion.

MANEUVER: The patient is asked to relax the mus-cles of the forearm. While the examiner holds thedistal forearm firmly, the wrist is passively extendedto its endpoint. Perform this cautiously in the acutelyinjured or inflamed wrist.

INTERPRETATION: Mild symptoms and normal rangeof motion are seen with simple wrist sprains andmild arthritis. Moderate symptoms and a 20% to50% loss of range of motion are characteristic ofchondral fractures and moderate arthritis. Acutegout, navicular fracture, Colles fracture, and perilu-nate dislocation are characterized by severe symp-toms and a loss of more than 50% of range of mo-tion. Patients with a septic joint or displaced distalradius fractures refuse to move at all.

FIGURE 5–2. Measure the range of motion of the wrist andassess endpoint pain and stiffness in extension (dorsiflexion).

MANUAL GRIP STRENGTH MEASUREMENT

SUMMARY: Grip strength measurement is the mostobjective but indirect measurement of the integrityand strength of the supporting muscles of the wrist.Gripping can be influenced by arthritis of the intrin-sic joints of the hands and wrist, intrinsic muscles ofthe hand, and forearm flexor tendons and muscles.

MANEUVER: Grip strength can be crudely estimatedby manual gripping of the examiner’s fingers.However, physical measurement using a dy-namometer is much more accurate and repro-ducible. An alternative method involves compress-ing a partially inflated blood pressure cuff.

INTERPRETATION: Grip strength is reduced in a consistent manner by disuse atrophy, wrist arthritis,CTS, hand arthritis, severe epicondylitis, and C8cervical radiculopathy. Inconsistent measurement of grip strength is seen with malingering.

FIGURE 5–3. Manual grip strength measurement to as-sess forearm muscle strength.


GRIP STRENGTH MEASUREMENT

SUMMARY: Grip strength measurement is the mostobjective but indirect measurement of the integrityand strength of the supporting muscles of the wrist.

MANEUVER: The average of three consecutive read-ings using the dynamometer provides an accurateand reproducible measurement of gripping andforearm muscle strength. An alternative method involves compressing a partially inflated bloodpressure cuff.

INTERPRETATION: Grip strength is reduced in a consistent manner by disuse atrophy, wrist arthritis,CTS, hand arthritis, severe epicondylitis, and C8cervical radiculopathy. Inconsistent measurement of grip strength is seen with malingering.

FIGURE 5–4. Grip strength measurement to assess forearmmuscle strength.

STRENGTH ASSESSMENT

OBJECTIVE: Strength assessment using resistancebands is another objective measurement of the in-tegrity and strength of the supporting forearm mus-cles. It also educates the patient on the importantrole of physical therapy exercises in the recoveryphase of treatment.

MANEUVER: Forearm strength is measured in exten-sion (depicted here) or in flexion (the opposite di-rection). A progressive number of standard 10-10resistance bands are placed over the patient’smetacarpal phalangeal joints (extension) or thepalm (flexion). The patient is asked to pull themapart, keeping the wrists perfectly straight. Side-to-side comparisons are made.

INTERPRETATION: Forearm muscle strength measure-ments are reduced in a consistent manner by disuseatrophy, wrist arthritis, CTS, hand arthritis, severeepicondylitis, and C8 cervical radiculopathy.Inconsistent measurement of grip strength is seenwith malingering.

FIGURE 5–5. Strength assessment of the forearm muscles.

WRIST 87

INSPECT THE DORSUM

SUMMARY: The dorsum of the hand is inspected forlocalized swelling arising from the joint, the focalswelling of a dorsal ganglion, and diffuse swellingover the extensor tendons.

MANEUVER: Simple inspection of the dorsum of thewrist can be combined with palpation to define thecharacteristics of the swelling.

INTERPRETATION: Radiocarpal joint swelling will lo-calize directly over the joint, filling in the naturaldepression atop the navicular. The soft cysticswelling of a ganglion is similarly located but withmore defined edges. The swelling accompanyingdorsotenosynovitis and RSD extends over a greaterarea and obscures the dorsal tendons and carpalbones.

FIGURE 5–6. Inspect the dorsum for wrist swelling, ganglion,or dorsotenosynovitis.

PALPATE THE RADIAL STYLOID AND COMPRESS THE CMC JOINT

SUMMARY: The CMC joint of the thumb articulateswith the trapezius bone of the wrist, and the exten-sor and abductor tendons of the thumb form theanatomic snuffbox, both of which are in close proximity to the radial side of the wrist.

MANEUVER: The wrist is placed in neutral position,radial side up. The most distal portion of the radialstyloid is identified, marked, and palpated for localtenderness. Similarly, the CMC joint is compressed inan anteroposterior direction to assess its involvement(see Figure 5-19).

INTERPRETATION: Twenty percent to 25% of pa-tients with de Quervain’s tenosynovitis or CMCjoint osteoarthritis complain of wrist pain ratherthan thumb pain.

FIGURE 5–7. Palpate the radial styloid and compressthe CMC joint to screen for thumb involvement.



TRIAGE TO X-RAY For the patient who has a history oftrauma, is at risk of bony injury, or presents with a severewrist sprain:

• Order three views of the wrist for patients with a historyof fall to an outstretched arm or direct blow to the wrist(distal radius or navicular fracture, perilunate dislocation,or triangular cartilage injury).

• Order three views of the wrist for patients with significantloss of range of motion in extension and flexion (post-traumatic osteoarthritis or inflammatory arthritis, such asrheumatoid arthritis).

• Order coned-down views of the navicular for a patientwith a history of trauma, a loss of 50% of the range of mo-tion of the wrist, and navicular tenderness (navicular frac-ture, greater anatomic detail).

• Order the carpal tunnel view for patients with severe wristsprain and concurrent development of CTS symptoms(perilunate dislocation).

TRIAGE TO THE LAB For patients with severe limita-tion of wrist motion and signs of inflammation (gout, acutearthritis, or septic arthritis):

• Order a complete blood cell count, uric acid, and erythro-cyte sedimentation rate for patients with acute pain, ex-quisite tenderness, and poor range of motion of the wristwith signs of active inflammation (gout or acute arthritis);include blood cultures if the acute inflammatory changesare accompanied by significant fever or concurrent signsof infection elsewhere in the body (septic arthritis).

CONSIDER A BONE SCAN For patients with incon-clusive exams but a suspicion of RSD, osteomyelitis, or sub-tle fracture accompanying severe wrist sprain.

CONSIDER MRI For patients with suspected navicularfracture to determine the integrity of the navicular bone orits blood supply (avascular necrosis) and to evaluate the tri-angular cartilage in patients with lateral wrist pain.

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate wrist pain and stiffness, unre-stricted movement of the joint, normal alignment, and nor-mal grip strength.

• Avoid the extremes of movement, keeping the wrist inneutral position.

• Immobilize the wrist with a Velcro wrist splint.• Limit repetitious gripping and grasping.• Limit lifting to less than 10 pounds.• Avoid exposure to vibration and cold.• Apply ice over the dorsum of the wrist up to four times

a day.• Perform gentle passive stretching exercises in flexion and

extension daily.

DETAILED EXAMINATION: SPECIFIC WRISTDIAGNOSES

Perform a detailed examination of the wrist if injury has oc-curred. Symptoms are persistent or chronic. Wrist pain andstiffness are moderate to severe. Range of motion is im-paired, or the patient’s grip is dramatically affected.

TINEL SIGN COMBINED WITH A CONSISTENT HISTORY

SUMMARY: The carpal tunnel is formed by the firstrow of carpal bones (navicular, lunate, pisiform,and triquetral) and the transverse carpal ligament. It contains nine flexor tendons and the mediannerve. Because the Tinel sign is positive in only70% of cases, it must be combined with a historyof paresthesia or hypesthesia that is consistent witha median nerve distribution.

MANEUVER: The wrist is placed in neutral position.Using the index finger, the wrist is vigorouslytapped at the junction of the palmaris longus andthe flexor creases. The tapping should encompassan area the size of a quarter.

INTERPRETATION: For the Tinel sign to be consideredpositive, the patient’s pain must be reproduced, andthe paresthesia should be distinctly different from theresponse on the contralateral side. Note that falsepositives occur in overly sensitive patients.

FIGURE 5–8. Tinel sign combined with a consistent his-tory to screen for CTS.

WRIST 89

WRIST SPRAIN Injuries to the wrist represent a spectrum ofconditions that include the simple wrist sprain (a strained liga-ment), perilunate dislocation (a torn ligament), chondral fracture,

and navicular fracture. Painful loss of range of motion is the keyto distinguishing these conditions. Simple sprains rarely showmore than a 10% loss of flexion and extension.

RADIOCARPAL JOINT LINE TENDERNESS

SUMMARY: The junction of the distal radius, navicu-lar, and lunate bones occurs directly under the in-tersection of the extensor tendon of the index fingerand a line drawn perpendicular to the most distalaspect of the radius.

MANEUVER: The wrist is placed in neutral position.The ulnar styloid is identified (x), and the extensor tendon of the index finger is identified (arrows). Thenavicular is palpated at the intersection of the distalradius and the first extensor tendon. The lunate ispalpated between the ulnar styloid and the navicu-lar bone. Tenderness may be enhanced by pas-sively flexing and extending the wrist in an arc of50 degrees.

ADDITIONAL SIGNS: Mild swelling over the dorsumand a nearly normal range of motion of the wristcomplete the examination.

INTERPRETATION: Radiocarpal joint line tendernessmust be combined with range of motion measure-ments in flexion and extension to distinguish a sim-ple wrist sprain from higher degrees of wrist trauma.

FIGURE 5–9. Radiocarpal joint line tenderness for the diag-nosis of wrist sprain.

NORMAL X-RAYS

SUMMARY: A sprained wrist is an injury to the supporting ligaments of the radiocarpal joint.Radiographs of simple wrist sprains are normal.With the exception of the nondisplaced navicularfracture, radiographs of the injured wrist (e.g., frac-ture, dislocation) or acute arthritic flare are abnor-mal. The posteroanterior, lateral, and oblique viewsare used to exclude fracture, perilunate dislocation,and underlying arthritis.

DIAGNOSIS: Simple wrist sprain with a normal pos-teroanterior radiograph of the wrist.

INTERPRETATION: The normal wrist is characterizedby 2 mm articular width between the radius, navicu-lar, and lunate bones (identical to the width of the in-tercarpal joints), normal bony position and align-ment, and well-mineralized bone.

FIGURE 5–10. Normal x-rays of the wrist are used to excludefracture and arthritis.


RADIOCARPAL JOINT ARTHRITIS Radiocarpal jointarthritis is an uncommon problem. Whether due to rheumatoidarthritis or the much less common posttraumatic osteoarthritis,

the severity of involvement of the joint is directly related to the lossof flexion and extension.

RADIOCARPAL JOINT DORSAL SWELLING AND TENDERNESS

SUMMARY: Wrist swelling and tenderness preferen-tially affect the dorsum of the wrist, directly over thenavicular bone. With progressive joint involvement,the normal concavity and bony firmness over thenavicular bone are replaced by increasing dome-like swelling and tenderness.

MANEUVER: The wrist is placed in neutral position.The ulnar styloid is identified, and the extensor ten-don of the index finger is identified. The navicularis palpated at the intersection of the distal radiusand the first extensor tendon. The lunate is palpatedbetween the ulnar styloid and the navicular bone.Tenderness may be enhanced by passively flexingand extending the wrist in an arc of 50 degrees.

ADDITIONAL SIGNS: Increasing swelling over thedorsum and variable degrees of heat and rednesscomplete the examination.

INTERPRETATION: Wrist joint tenderness andswelling are moderate with osteoarthritis and se-vere with gout, Colles fracture, navicular fracture,perilunate dislocation, and septic arthritis.FIGURE 5–11. Radiocarpal joint dorsal swelling and

tenderness.

RANGE OF MOTION OF THE RADIOCARPAL JOINT

SUMMARY: The greater the involvement of the wristwith acute swelling and inflammation, the greaterthe impairment of range of motion.

MANEUVER: The patient is asked to relax the mus-cles of the forearm. While the examiner holds the distal forearm firmly, the wrist is passively flexedand extended to its endpoints. Perform this cau-tiously in the acutely injured or inflamed wrist.Normal flexion and extension average 90 and 80 degrees, respectively.

INTERPRETATION: Mild symptoms and normal rangeof motion are seen with simple wrist sprains andmild arthritis. Moderate symptoms and a 20% to50% loss of range of motion are characteristic ofchondral fractures and moderate arthritis. Acutegout, navicular fracture, Colles fracture, and perilu-nate dislocation are characterized by severe symp-toms and a loss of at least 50% of range of motion.Patients with a septic joint or displaced distal radiusfractures refuse to move at all.FIGURE 5–12. Assess range of motion of the radiocarpal

joint.

WRIST 91

X-RAY CHANGES

CASE: This 47-year-old high school basketballcoach described a history of multiple wrist sprainsover the last 20 years. The patient never had adocumented fracture on previous x-rays of the wrist.His exam demonstrated mild dorsal swelling, flex-ion of 65 to 70 degrees, extension of 60 to 65 de-grees, and mild endpoint stiffness and pain.

DIAGNOSIS: Osteoarthritis of the radionavicularjoint. The articular cartilage between the radiusand the navicular bone is narrowed (single largearrow), and the gap between the navicular and lu-nate is widened (2 small arrows). The normal artic-ular width between any of the carpal bones shouldbe 2 mm.

DISCUSSION: Osteoarthritis of the wrist is rare out-side the setting of previous trauma. However, wrist involvement is common in well-established rheuma-toid arthritis.

FIGURE 5–13. X-ray changes to confirm radiocarpal osteoarthritis.

LOCAL ANESTHETIC BLOCK OR ASPIRATION

SUMMARY: In order to distinguish the variouscauses of wrist effusion, the radiocarpal joint is as-pirated from the dorsal aspect.

POSITIONING: The wrist is placed flat on the tablewith the palm side down.

SURFACE ANATOMY: Distal radius, navicular, andextensor digitalis of the index finger.

POINT OF ENTRY: In the angle made by the inter-section of the radius and the extensor tendon.



DEPTH: 1⁄2 to 5⁄8 inch (1⁄4 inch is too superficial).

ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL, extensorretinaculum; 1⁄4 mL intra-articularly.

FIGURE 5–14. Local anesthetic block or aspiration to con-firm the involvement of the wrist joint.


DORSAL GANGLION CYST Ganglion cysts are located inthe dermal layer of the skin. They are typically round, vary in cir-cumference up to the size of a quarter, and can be multilobulated.

Their variability in size, shape, and firmness depends on theamount of excessive synovial or tenosynovial fluid produced by the adjacent joint or tendon.

DORSAL GANGLION

SUMMARY: The diagnosis of a dorsal ganglion ismade by simple inspection and palpation. Morethan 90% of dorsal ganglia result from an excessproduction of synovial fluid. A sinus tract connectsthe cyst to the joint located between the navicularand lunate bones. Ten percent of ganglia result fromthe excessive tenosynovial fluid produced by the ex-tensor tendons.

MANEUVER: The cyst is palpated for tension, fluctu-ance, and mobility. Passive movement of the fingersis performed to determine whether the cyst is at-tached to the tenosynovial sheath.

ADDITIONAL SIGNS: Passive movement of the wristshould be normal unless underlying arthritis is pres-ent. If the ganglion moves with passive movementof the fingers, the ganglion probably arises fromthe extensor tendon sheath.

INTERPRETATION: The excessive production of fluidrepresents overuse or previous injury to the joint orits supporting tendons.

FIGURE 5–15. Dorsal ganglion inspection at the wrist.

DIAGNOSTIC ASPIRATION

SUMMARY: The diagnosis is confirmed by the aspi-ration of the thick, tenacious, nonbloody fluid fromthe cyst.

POSITIONING: Wrist flat on the table, palm sidedown.

SURFACE ANATOMY: The four dorsal extensor ten-dons of the fingers are covered by the extensor reti-naculum located below the subcutaneous layer.

POINT OF ENTRY: At the base of the cyst.

ANGLE OF ENTRY: Parallel to the skin.

NEEDLE: 5⁄8 inch, 25 gauge for anesthesia and 1 inch, 18 gauge for aspiration.


ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL subcutaneously.

FIGURE 5–16. Diagnostic aspiration to confirm a dorsalganglion.

WRIST 93

DORSOTENOSYNOVITIS Inflammation of the extensor ten-dons of the hand is called dorsotenosynovitis. It is characterized bydorsal pain, swelling, and acute inflammation. In addition, thepain of active tenosynovitis is uniquely aggravated by resisted ex-

tension and passive flexion of the fingers. The latter sign distin-guishes it from the conditions that cause dorsal swelling (simpleedema, cellulitis, fracture, and RSD).

DORSAL TENOSYNOVITIS

CASE: This middle-aged office worker presented withacute swelling, pain, and warmth over the back ofher hand that was aggravated by typing and otherfine movements of the fingers. The patient had a his-tory of hypertension treated with thiazide diureticsbut no history of rheumatoid arthritis, gout, or otherrheumatic diseases. She denied any direct traumaor unusual use of her wrist and hand. The localizedpain and swelling were aggravated by resisting theextension of the middle three digits. Uric acid waselevated.

DIAGNOSIS: Acute dorsal tenosynovitis due to gout.

INTERPRETATION: Aspiration of fluid is not possiblewith acute tenosynovitis. Distinguishing it from RSDand cellulitis is based solely on clinical examination.

FIGURE 5–17. Dorsal tenosynovitis is characterized by dif-fuse dorsal swelling that is aggravated by movement of the fingers.

DIAGNOSIS OF DORSOTENOSYNOVITIS

SUMMARY: No specialized testing is available toconfirm the diagnosis of dorsotenosynovitis. Thecombination of dorsal swelling, pain reproduced by resisting finger extension, or pain aggravatedby passive finger flexion remain the hallmarks ofthis local musculoskeletal process.

MANEUVER: While holding the forearm fixed, theexaminer places the other hand on the fingers andpassively presses the extensor tendons downward.Bending the wrist 45 degrees enhances the activedorsotenosynovitis. This is combined with active resistance of the extensor tendons to confirm the diagnosis.

INTERPRETATION: Whereas the swelling and inflam-matory changes of cellulitis, RSD, and dorsoteno-synovitis are indistinguishable, only the active in-flammation of the extensor tendons is aggravatedby the passive stretching and active resistance maneuvers.

FIGURE 5–18. The diagnosis of dorsotenosynovitis ismade strictly on clinical grounds.


THUMB DIAGNOSES PRESENTING AS WRIST PAINThe complete examination of the wrist requires an examination of the CMC joint and the extensor tendons of the thumb. Approx-

imately 25% of patients with de Quervain’s tenosynovitis andCMC arthritis describe their symptoms as wrist pain rather thanpain in the thumb (see Chapter 6).

COMPRESSION OF THE BASE OF THE THUMB

SUMMARY: Twenty percent to 25% of patients withde Quervain’s tenosynovitis or CMC joint osteo-arthritis complain of wrist pain rather than thumbpain.

MANEUVER: The wrist is placed in neutral position,radial side up. The examiner grasps the base of thethumb just beyond the anatomic snuffbox. The syn-ovial lining and the base of the metacarpal aresqueezed together using the thumb and finger. The compression can be enhanced by circumduct-ing the thumb while continually holding pressure.

ADDITIONAL SIGNS: Compressing the base of thethumb in the anteroposterior direction, noting crepi-tation with circumduction of the joint, and estimat-ing the bony shelf sign suggest active arthritis of the base of the thumb.

INTERPRETATION: Distinguishing CMC joint strainand osteoarthritis from primary involvement of thewrist requires local anesthetic block placed at thebase of the thumb.FIGURE 5–19. Compression of the base of the thumb is

the most effective maneuver to elicit pain from an osteoarthritisflareup of the CMC joint.

PALPATE THE RADIAL STYLOID

SUMMARY: Twenty percent to 25% of patients withde Quervain’s tenosynovitis or CMC joint os-teoarthritis complain of wrist pain rather than thumbpain. The extensor pollicis longus, extensor pollicisbrevis, and abductor pollicis longus form theanatomic snuffbox. All three tendons course alongthe distal radial styloid to attach to the interpha-langeal, metacarpal phalangeal, and CMC jointsof the thumb, respectively.

MANEUVER: The wrist is placed in neutral position,radial side up. The most distal portion of the radialstyloid is identified, marked, and palpated for localtenderness.

ADDITIONAL SIGNS: Radial styloid tenderness,pain aggravated by resisting extension of thethumb, and pain aggravated by stretching the ex-tensor tendons in flexion (the Finkelstein maneuver)suggests active de Quervain’s tenosynovitis.

INTERPRETATION: Distinguishing de Quervain’s fromprimary involvement of the wrist requires local anes-thetic block over the radial styloid (see Chapter 6).

FIGURE 5–20. Palpate the radial styloid to assess the de-gree of de Quervain’s tenosynovitis.

WRIST 95

CARPAL TUNNEL SYNDROME Median nerve compressionat the wrist (CTS) or in the forearm (pronator teres syndrome)presents with a variety of symptoms depending on the extent ofnerve compression, the length of time symptoms have been present,and previous surgical intervention. The symptoms include pares-

thesia or hypesthesia of the wrist and hand, variable degrees ofsubjective weakness, and true loss of strength and atrophy. If thereis a history of neck pain, whiplash, arthritis of the neck, or necksurgery, studies should be obtained to evaluate for concurrent C6radiculopathy.

TINEL SIGN

SUMMARY: The carpal tunnel is formed by the firstrow of carpal bones (navicular, lunate, pisiform,and triquetral) and the transverse carpal ligament. It contains nine flexor tendons and the mediannerve. Because the Tinel sign is positive in only70% of cases, it must be combined with a historyof paresthesia or hypesthesia that is consistent witha median nerve distribution.


ADDITIONAL SIGNS: The Phelan sign, loss of two-point discrimination of the fingertips, loss of lighttouch and pain sensation, weakness of thumb op-position, and thenar muscle atrophy are the addi-tional signs of median neuropathy.

INTERPRETATION: For the Tinel sign to be consid-ered positive, the patient’s pain must be repro-duced, and the paresthesia should be distinctly dif-ferent from the response on the contralateral side.

FIGURE 5–21. Tinel sign to assess the degree of CTS.

NERVE CONDUCTION VELOCITY

CASE: This professional hairdresser complained ofnumbness and tingling of the thumb and index fin-ger. She feels her strength is normal. Nerve con-duction velocity testing demonstrated a slowing ofthe median nerve across the wrist.

DIAGNOSIS: CTS from repetitious use.

DISCUSSION: Nerve conduction velocity testing ismoderately sensitive in the diagnosis of persistentor progressive symptoms caused by median nervecompression. Approximately 70% of patients withCTS will have an abnormal test.

FIGURE 5–22. Nerve conduction velocity to confirm CTSand determine its severity.


EXAMINATION MANEUVERS DIAGNOSIS CONFIRMATION

Pain and stiffness at full wrist flexion or extension 1. Wrist sprain Wrist series x-ray is normal

Minimal dorsal swelling Resolves in 2 wk

Minimal tenderness over the navicular and lunate bones

Loss of full wrist flexion and extension Radiocarpal arthritis Wrist series x-ray or local anesthetic placed in the radiocarpal joint

Dorsal swelling and tenderness

Cystic swelling over the dorsum of the wrist Dorsal ganglion Simple aspiration of thick, gelatinous fluid

Hypesthesias or paresthesias by history 2. Carpal tunnel syndrome Medial nerve block with anesthetic or nerve conduction velocity testing

� Tinel or Phelan sign

Pain with resisted finger extension Dorsal tenosynovitis Anesthetic placed alongside the tenosynovial sheath

Diffuse swelling over the dorsum

Point tenderness over the lateral wrist just distal Triangular cartilage injury MRI of the wrist or anesthetic placed in the ulnocarpal jointto the ulnar styloid

Pain with forced ulnar deviation

Loss of full wrist flexion and extension Navicular fracture Wrist series x-ray or bone scan

Dorsal swelling and tenderness

Point tenderness over the dorsum or in the snuffbox


WRIST 97

NONDISPLACED COLLES FRACTURE

SUMMARY: Fractures of the distal radius are classi-fied according to the direction of angulation of theradius and whether the radiocarpal joint or radioul-nar joint is involved. The Colles fracture involvesthe distal 2 cm of the radius, is angled dorsally,and may or may not involve the joint. The Smithfracture is identical to the Colles fracture except forthe volar angulation. The Barton fracture is a frac-ture or dislocation with the predominant finding ofwrist dislocation by clinical criteria and x-ray find-ings. Note the fracture of the ulnar styloid, thetransverse, compacted fracture of the radius, andthe oblique fracture extending proximally, all mini-mally displaced.

IMMOBILIZATION: (1) Order x-rays, classify thetype of fracture, determine the degree of displace-ment or dislocation of the adjacent joints, and as-sess the integrity of the median nerve. (2) Performhematoma, axillary, or Bier block anesthesia. (3)Perform closed reduction using finger trap tractionwith proximal brachial countertraction. (4) Repeatthe x-rays to ensure a slightly volar tilt and restora-tion of the length of the radius. (5) Use a sugartong splint for the first 48 hours to allow room forswelling. (6) After 48 hours, replace the splint witha short arm cast for undisplaced fractures or a longarm cast with slight flexion and ulnar deviation fordisplaced fractures (if unstable, refer to surgery).(7) Repeat x-rays at 4 to 6 weeks to assess healing.(8) Use a Velcro wrist splint with a metal stay for 3 to 4 weeks after immobilization. (9) Start passiverange of motion exercises of the wrist in dorsiflex-ion and volarflexion after fixed immobilization.

SURGICAL REFERRAL: Colles fractures that are re-ducible but unstable, comminuted, or intra-articular,Smith fractures, and Barton fractures may requireopen reduction and internal fixation. These frac-tures should be managed by a fracture specialist.Pin fixation or open reduction is necessary for afracture that remains unstable despite closed reduc-tion, for a Barton fracture or dislocation, for a com-minuted fracture, and for a displaced fracture (es-pecially an intra-articular fracture).

FIGURE 5–23. Distal radius fracture: nondisplacedColles fracture.

COMMON WRIST FRACTURES

SUMMARY

Because of its peripheral location and the injuries sustainedduring falls to an outstretched arm, fractures of the wrist arevery common. The prevalence of wrist fractures is slightly

less than that of ankle fractures. Distal radius fractures andfractures of the navicular make up more than 90%. Of thevariety of fractures that affect the distal radius, the Collesfracture is the most common. Most Colles fractures are ei-ther nondisplaced or show minimal displacement that isreadily reduced and stable. The majority of these fracturescan be managed by the primary care provider.


DISPLACED AND FORESHORTENED COLLESFRACTURE

CASE: This older woman with advanced osteoporo-sis fell on an outstretched arm. She was unable tomove the wrist in any direction. Her wrist showeddramatic dorsal angulation.

PROGNOSIS: The prognosis depends on the adequacy of reduction, the age of the patient, thepresence of osteoporosis, and whether the fractureextended into the joint. Intra-articular and extra-articular fractures that result in a foreshortened orangled radius (�5 mm or 20 degrees, respectively)have a greater incidence of poor range of motionof the wrist, late-onset osteoarthritis, and mediannerve damage.FIGURE 5–24. Distal radius fracture: displaced and

foreshortened Colles fracture.

NAVICULAR FRACTURE

SUMMARY: The early diagnosis of navicular fracturemust rely on a high index of suspicion, a compre-hensive examination of the wrist, and serial radio-graphs. Because the fracture is small and oftennondisplaced, it may not be detectable on initialplain radiographs. The diagnosis is suggested bydramatic local tenderness (either in the snuffbox orover the dorsum), the acute loss of 50% of flexionand extension, and dramatic dorsal swelling.

IMMOBILIZATION: If the clinical findings suggest thepossibility of navicular fracture, the thumb and wristmust be immobilized using a thumb spica short armcast or at least a thumb spica Velcro wrist brace un-til the patient is seen by the fracture specialist.

SURGICAL REFERRAL: Surgical referral to a handspecialist is strongly recommended.

PROGNOSIS: Immobilization is imperative to avoidthe potential complications of nonunion and avas-cular necrosis of the navicular. Incomplete recoveryof range of motion and late-onset osteoarthritis ofthe wrist result when the fracture fails to heal.

FIGURE 5–25. Navicular fracture.

WRIST 99

AVASCULAR NECROSIS OF THE NAVICULAR

CASE: This 52-year-old woman sustained a penetrat-ing injury of her wrist while using an electric drill.The drill entered the dorsum of the wrist. Her exami-nation demonstrated maximum tenderness over thenavicular with moderate tenderness in the snuffboxand swelling over both areas. She was treated in athumb spica short arm cast for 21⁄2 months. Shenever fully recovered her wrist range of motion orher grip strength. Months after the injury she mani-fested mild carpal tunnel symptoms.

DIAGNOSIS: Avascular necrosis of the navicular.

SUMMARY: The navicular bone has a tenuous bloodsupply at best. When the bone is fractured, the prox-imal blood flow is interrupted, and the distal seg-ment undergoes avascular necrosis. Approximately5% to 10% of navicular fractures undergo collapseand subsequent sclerotic bony change. Loss of thenormal integrity of the navicular leads to late-onsetosteoarthritis of the radionavicular joint. Most pa-tients with this complication fail to regain half thenormal range of motion of the wrist joint.

FIGURE 5–26. Avascular necrosis of the navicular afterfracture.

PERILUNATE DISLOCATION

SUMMARY: Perilunate dislocation results from a se-vere blow to the volar wrist and is characterized bysevere wrist sprain. The supporting ligaments aretorn, and the lunate rotates on its axis. The abnor-mal position distorts the carpal tunnel, leading tomedian nerve symptoms.

IMMOBILIZATION: Initially, the patient is placed ina posterior splint to allow for swelling.

REFERRAL: Surgical referral is mandatory.

PROGNOSIS: The prognosis is good in most pa-tients, although avascular necrosis and late-onset steoarthritis can result from this injury.

FIGURE 5–27. Perilunate dislocation associated with a severe wrist sprain.


• Loss of flexion of the wrist is the first sign of a develop-ing effusion of the radiocarpal joint.

• The absolute loss of flexion and extension is directlycorrelated with the severity of arthritis, wrist sprain, andthe more advanced traumatic conditions, such as navic-ular fracture and perilunate dislocation.

• Chronic irritation of the wrist causes an overproductionof synovial fluid. Because of the limited capacity of thesynovial cavity, this excess fluid leaks out of the jointthrough a sinus and into the subcutaneous tissues. Inthis superficial location, the body isolates the fluid byencapsulation; a thick wall forms around the fluid,thereby creating the ganglion cyst.

• Volar ganglia are uncommon and most often occur atthe base of the thumb adjacent to the insertion of theflexor carpi radialis tendon and the radial artery.

CLINICAL PEARLS

• More than 90% of ganglia are located on the dorsum ofthe wrist, the majority of which arise from the radio-carpal joint. Fewer than 10% arise from the tenosyn-ovial sheaths that envelop the extensor tendons of thethumb and fingers.

• CTS can be graded as intermittent sensory loss, contin-uous sensory loss, combined sensorimotor loss, or sen-sorimotor loss with atrophy. Increasing pressure over themedian nerve gives rise to increasing neurological im-pairment, typically beginning with paresthesia and pro-gressing to hypesthesia, dysesthesia, motor weakness,and motor weakness with muscular atrophy.

101

CHAPTER 6: THUMB


Diagnoses

OsteoarthritisCarpometacarpal jointPosttraumatic arthritis of the metacarpal

phalangeal and interphalangeal jointsMucinoid cysts atop the joint

Extensor tendonsDe Quervain’s tenosynovitis

Flexor tendonsTrigger thumbFixed locked digit

Gamekeeper’s thumb

Referred painCarpal tunnel syndrome

C5–C6 radiculopathyReflex sympathetic dystrophy

Confirmations

Examination; x-rays: hand seriesExamination; x-rays: hand series

Examination, simple puncture

Examination, local anesthetic block

Examination, local anesthetic blockExamination

Examination, local anesthetic block

Nerve conduction velocity testing, local anestheticblock

Cervical spine x-rays, MRI, electromyographyExamination, bone scan

fuse hand pain seen with reflex sympathetic dystrophy. Aswith all referred types of pain, the examination of thethumb is free of local tenderness, loss of range of motion,or pain aggravation with movement.

SYMPTOMS Conditions directly affecting the thumbcause symptoms of localized pain and sensitivity, swellingor deformity, and decreased gripping, grasping, and pinch-ing. The latter impairments of function are nonspecific andcan be caused by any condition affecting the thumb, indi-vidual fingers, or entire hand. Therefore, the key to estab-lishing the correct diagnosis is the precise localization of thepatient’s pain and swelling.

Pain at the base of the thumb, the most common thumbcomplaint, reflects the nearly universal occurrence of arthri-tis of the CMC joint and the pain that accompanies simplesprains of the joint. Often, the patient points to the snuff-box or rubs along the proximal metacarpal when describingthe condition. Patients also complain of the characteristicdeformity (the “shelf sign” from the bony enlargement ofthe joint) or the swelling that forms in the anatomic snuff-box and distorts the radial side of the wrist.

Pain over the distal radius that extends into the anatomicsnuffbox is the classic pain pattern of de Quervain’s tenosyn-ovitis. This pain can be felt over a wide area and can eventravel in a retrograde fashion up the forearm.

Pain over the flexor aspect of the MP joint is character-istic of the inflammatory stage of flexor tenosynovitis. Thisdime-sized area of pain is localized over the flexor creases inthe palm (the same site as the local tenderness on examina-tion of the flexor tendons). However, as the condition pro-gresses, the pain may be overshadowed by the mechanicallocking described at the distal IP joint (the mechanical stageof the condition). Patients with severe tendon swelling maycomplain of the end stage condition of flexor tenosynovitis,fixed locked digit.

Pain along the inner aspect of the MP joint is seen withgamekeeper’s thumb, simple sprains, and partial disloca-tions. The ulnar collateral ligament is much more likely to beinjured with repetitious use of the thumb, the twisting mo-tions of a ski pole injury, or hyperextension sports injuries.

Pain localized to the IP joint is the least common pre-sentation. Tuft fractures and ligament injures are the mostcommon causes of IP joint involvement. The joint is sparedin most cases of rheumatoid arthritis. Osteoarthritis of theIP joint results almost exclusively from old and remotetrauma.

EXAMINATION Examination of the thumb begins witha functional assessment of gripping, grasping, and pinchingand range of motion testing of its three joints. These ma-neuvers provide objective measurements of function, a pre-liminary assessment of the severity of the condition, andimportant clues to the specific diagnosis.

Next, specific maneuvers for each diagnosis are per-formed based on the location and description of the painand the clues provided by the functional screening tests.Pain at the base of the thumb, visible swelling in theanatomic snuffbox, or bony enlargement of the proximalmetacarpal suggests osteoarthritis of the CMC joint. Pain


INTRODUCTION The differential diagnosis of thumbpain is dominated by the wear-and-tear arthritis of the baseof the thumb, carpometacarpal (CMC) osteoarthritis. Thisis a universal condition that nearly everyone develops tosome degree in the fifth and sixth decades of life. Despiteits prevalence, patients may not necessarily develop symp-toms significant enough to cause pain or interfere withoverall hand function. By contrast, arthritis affecting themetacarpal phalangeal (MP) and interphalangeal (IP) jointsis uncommon and almost always is the result of previoustrauma.

The second most common condition that affects thethumb is carpal tunnel syndrome. Most patients with mildto moderate median nerve entrapment develop varying de-grees of thumb paresthesia, hypesthesia, or subjectivethumb weakness. Patients with advanced nerve compressionalways experience objective thumb weakness and thenarmuscle atrophy caused by the recurrent median nerve involvement.

Repetitive use of the thumb also causes irritation and in-flammation of the supporting tendons (tenosynovitis).Repetitive gripping and grasping with pressure over the pal-mar aspect of the MP joint cause flexor tenosynovitis (trig-ger thumb). Repetitive gripping and grasping with activemovement of the wrist cause irritation and inflammation ofthe extensor and abductor tendons (de Quervain’s stenosingtenosynovitis). These periarticular conditions are character-ized by their focality and unidirectional aggravation on ex-amination of the thumb. Trigger finger is tender over thepalmar aspect of the MP joint and aggravated by isometri-cally resisted flexion. De Quervain’s tenosynovitis is tenderover the radial styloid and is aggravated by isometrically re-sisted extension and abduction. Contrast this with the examof the CMC joint. Tenderness is over the entire joint, andthe deep, poorly localizing pain is aggravated by movementin all directions. Injury to the thumb tendons is uncom-mon. Rupture of the extensor pollicis longus insertion leadsto the mallet thumb deformity.

Ligament injuries are exceedingly common. Simplesprains, partial dislocations, and repetitive stress to the sup-porting ligaments are for the most part benign. Unless theunderlying cartilage is damaged (chondral fracture leadingto late-onset posttraumatic osteoarthritis), these injuries areself-limited. The middle MP joint is most susceptible. Themost common injury is gamekeeper’s thumb, an injury tothe ulnar collateral ligament of the MP joint caused byrepetitive twisting type movements or hyperextension in-juries (ski pole injuries). The ligament can be stretched (firstdegree), partially torn (second degree), or completely torn oravulsed from the bone (third-degree injuries).

Because of its peripheral location and its unique role inthe hand, the thumb is susceptible to bony fracture.Nondisplaced fractures that do not involve the articularsurfaces can be managed with simple immobilization. Withthe exception of third-degree gamekeeper’s thumb andBennett and Rolando intra-articular fractures of the base ofthe metacarpal, most of these can be managed by nonsur-gical means.

Finally, carpal tunnel pain can be referred to the thumb.Similar to carpal tunnel syndrome, thumb pain, paresthesia,or hypesthesia is part of the clinical symptoms of C5–C6cervical radiculopathy. Thumb pain is always part of the dif-

THUMB 103

aggravated by compression of the joint in the anteroposte-rior direction or reproduced by the mortar and pestle ma-neuver distinguishes active inflammation of the joint fromsimple sprains and the more common asymptomatic bonyenlargement of the joint.

Pain localized at the MP joint may arise from the activeinflammation of flexor tenosynovitis (the inflammatorystage of trigger thumb), the injured ligament of game-keeper’s thumb, simple ligament sprains of the MP joint, orthe uncommon posttraumatic osteoarthritis of the MPjoint. The pain and local tenderness of active flexor tenosyn-ovitis (trigger thumb) are located directly over the flexorcreases in the palm. Locking or clicking of the IP joint or aloss of the normal smooth motion of the IP joint with ac-tive flexion confirms this diagnosis. Tenderness located onlyon the ulnar side of the MP joint is characteristic of game-keeper’s thumb (injury to the ulnar collateral ligament).This diagnosis is confirmed by reproducing the patient’spain by valgus stress testing of the joint. Tenderness on bothsides of the MP joint along with a loss of full flexion sug-gests either a strain of the MP joint (recent trauma) or post-traumatic arthritis.

Pain experienced primarily over the distal radial styloidbut often extending through the anatomic snuffbox to thebase of the thumb strongly suggests de Quervain’s tenosyn-ovitis. Distal radial styloid tenderness and pain aggravatedby isometrically resisted thumb extension are necessary todistinguish involvement of the extensor tendons from in-volvement of the CMC joint.

Finally, the examination of the thumb is completed witha screening maneuvers of the medial nerve for signs ofcarpal tunnel syndrome.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL THUMB FUNCTION

The next six maneuvers represent the minimal examinationof the patient presenting with thumb symptoms. Range ofmotion measurements and screening maneuvers for CMCarthritis, trigger thumb, de Quervain’s tenosynovitis, andcarpal tunnel syndrome provide enough information totriage to x-ray, order appropriate labs, suggest general treat-ment recommendations, or proceed to more detailed exam-ination and treatment.

1. Measure gripping and grasping and perform range ofmotion testing of flexion and extension of theCMC, MP, and IP joints.

2. Compress the CMC joint in the anteroposterior direction.

3. Palpate the lateral joint lines of the MP and IP joints.4. Palpate the flexor tendons over the flexor creases in

the palm (trigger thumb).5. Palpate the extensor tendons over the radial styloid

(de Quervain’s tenosynovitis).6. Check the integrity of the ulnar collateral ligament

of the MP joint (history of trauma).7. Perform the Tinel and Phelan maneuvers for carpal

tunnel syndrome.

ESSENTIAL EXAMINATION OF THE THUMBBOX 6-1

OPENING AND CLOSING THE HAND

SUMMARY: Full function of the thumb requires normal movement of the three joints, normally func-tioning flexor and extensor tendons, and an intactrecurrent median nerve and deep ulnar nerve.These maneuvers provide objective measurementsof function, a preliminary assessment of the severityof the condition, and important clues to the specificdiagnosis.

MANEUVER: The patient is asked to open and closethe hand, noting the patient’s ability to actively flexand extend the CMC, MP and IP joints.

INTERPRETATION: Smooth, painless, and completemovement of the thumb rules out significant arthritis,trigger thumb, and de Quervain’s tenosynovitis.Patients with metacarpal and phalangeal fracturesrefuse to complete this maneuver.

FIGURE 6–1. Opening and closing the hand to assess themovement and range of motion of the three joints of the thumb.



OBJECTIVE: Gripping can be influenced by arthritisof the intrinsic joints of the hands and wrist, intrin-sic muscles of the hand, and flexor tendons andmuscles of the forearm. Estimation of gripping andgrasping strength provides the most objective mea-surement of the severity of the condition affectingthe thumb.

MANEUVER: Grip strength can be crudely estimatedby manual gripping of the examiner’s fingers.However, physical measurement using a dynometeris much more accurate and reproducible. An alter-native method involves compressing a partially in-flated blood pressure cuff.

INTERPRETATION: Grip strength can be reduced bydisuse atrophy, arthritis, carpal tunnel syndrome, deQuervain’s tenosynovitis, and cervical radiculopathy.

FIGURE 6–2. Grip strength measurement using a partiallyinflated blood pressure cuff.


SUMMARY: The use of a dynamometer provides themost reproducible and objective measurement ofthe conditions affecting the thumb. It is the most ef-fective means of assessing the severity of each con-dition and the best criterion to assess the effective-ness of treatment. Gripping can be influenced byarthritis of the intrinsic joints of the thumb, thethenar muscles, and the flexor tendons.

MANEUVER: The strength of gripping can be accu-rately and reproducibly measured using a dy-namometer, comparing one side with another. Threereadings on each side are performed and averaged.Strength of the dominant side typically is 10%greater than that of the nondominant side, despiteambidexterity.

INTERPRETATION: Grip strength can be reduced bydisuse atrophy, arthritis, carpal tunnel syndrome, deQuervain’s tenosynovitis, and cervical radiculopathy.

FIGURE 6–3. Grip strength measurement by dynamometry.

THUMB 105

INSPECTION OF THE THUMB

SUMMARY: Simple inspection of the CMC, MP, and IP joints is used to screen for bony enlarge-ment, swelling, or subluxation. Note the promi-nence of the left base of the thumb relative to theposition of the distal radius, the shelf sign reflectingbony enlargement and subluxation.

MANEUVER: The patient is asked to relax the mus-cles of the hands and forearms. The hands areplaced in the anatomic position, radial side up. The widths of the joints in the anteroposterior direc-tion are compared side to side.

DISCUSSION: Osteoarthritis of the CMC joint is a nearly universal phenomenon. Osteoarthritis of the MP and IP joints almost always results fromprevious trauma.

FIGURE 6–4. Inspection of the thumb for CMC, MP, and IPjoint swelling, subluxation, enlargement, or bony enlargement.

RADIAL STYLOID PALPATION

SUMMARY: In the absence of trauma to the radius,radial styloid tenderness is the definitive sign of de Quervain’s tenosynovitis. The extensor pollicislongus and brevis and abductor pollicis longusform the outer edges of the anatomic snuffbox.The tendons of these muscles become inflamed asthey cross the radial styloid.


INTERPRETATION: In the absence of trauma to thedistal radius, radial styloid tenderness coupled withpain aggravated by resisting thumb extension ishighly suggestive of active tenosynovitis.FIGURE 6–5. Radial styloid palpation to screen for de

Quervain’s tenosynovitis.


TINEL SIGN

SUMMARY: The carpal tunnel is formed by the firstrow of carpal bones (navicular, lunate, pisiform,and triquetral bones) and the transverse carpal liga-ment. It contains nine flexor tendons and the me-dian nerve. Because the Tinel sign is positive inonly 70% of cases, it must be combined with a his-tory of paresthesia or hypesthesia that conforms toa median nerve distribution.



FIGURE 6–6. A localized history of thumb and finger pain,paresthesia, and hypesthesia combined with a Tinel sign toscreen for carpal tunnel syndrome.

PALPATION OF THE FLEXOR TENDONS

SUMMARY: Tenderness over the flexor tendons onthe palmar aspect of the MP joint is the optimalscreening maneuver for active flexor tenosynovitis.The flexor tendons are located in the midline andcourse down the finger to attach to the base of themiddle and distal phalanges. Within the flexor ten-don are two sesamoid bones located near the firstflexor crease.

MANEUVER: The flexor tendons are palpated overthe palmar aspect of the MP joint (arrow).

INTERPRETATION: Active tenosynovitis is diagnosedby demonstrating flexor tendon tenderness at thebase of the metacarpophalangeal joint combinedwith pain aggravated by passive stretching of thetendon in extension. If the tendon is sufficientlyswollen, it will fail to move freely under the A-1pulley of the tenosynovial sheath, resulting in me-chanical locking at the IP joint.

FIGURE 6–7. Palpation of the flexor tendons on the pal-mar aspect of the MP joint.

THUMB 107

COMPRESSION OF THE BASE OF THE THUMB

OBJECTIVE: Anteroposterior compression of theCMC joint along its joint lines is a more sensitivesign of active arthritis or significant strain than pal-pation over the base of the metacarpal or in thesnuffbox.

MANEUVER: The wrist is placed in neutral position,radial side up. The examiner grasps the base of thethumb just beyond the anatomic snuffbox. The syn-ovial lining and the base of the metacarpal aresqueezed together using the thumb and finger. Thecompression can be enhanced by circumductingthe thumb while continually holding pressure.

ASSOCIATED SIGNS: Swelling filling the anatomicsnuffbox, crepitation demonstrated by circumduc-tion of the joint, and the bony shelf sign suggest ac-tive arthritis of the base of the thumb.

INTERPRETATION: The examination of CMC strainoverlaps greatly with the examination of osteoarthri-tis. X-rays are normal with simple thumb strain,helping to distinguish the two conditions.

FIGURE 6–8. Compression of the base of the thumb isthe most effective maneuver to elicit pain from an osteoarthriticflareup of the CMC joint.


TRIAGE TO X-RAY For patients with a history of blunttrauma or hyperextension injury, swollen or bony enlarge-ment of one of the three joints, or severe impairment ofgripping and grasping:

• Order three views of the thumb for patients with a historyof blunt trauma, dislocation, or hyperextension injury(Bennett or Rolando fractures, the eggshell tuft fracture,or phalangeal fractures).

• Order three views of the thumb for patients with pain atthe base of the thumb (CMC joint osteoarthritis or simple strain) to confirm and define the severity of the un-derlying injury.

• Order three views of the thumb for patients with enlarge-ment or swelling of the MP or IP joint (posttraumatic os-teoarthritis or psoriatic arthritis).

• Order three views of the thumb for patients with a historyof hyperextension injury (tendon or ligament avulsion injury).

TRIAGE TO THE LAB For patients with acute swellingaccompanied by inflammatory signs, order a completeblood cell count, uric acid, and erythrocyte sedimentationrate for patients with acute pain, exquisite tenderness, andinability to grip or grasp (gout or acute arthritis).

CONSIDER A BONE SCAN For patients with diffusepain, diffuse hand swelling, and possible accompanying

discoloration and abnormal sweating (reflex sympathetic dystrophy).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate thumb pain and stiffness, un-restricted movement of the three joints, normal alignment,and no tendon contractures:

• Avoid repetitious gripping and grasping.• Avoid all vibration exposure.• Avoid prolonged contact with cold.• Wear thick leather gloves for protection.• Perform gentle range of motion exercises in flexion and

extension to prevent flexion contractures.

DETAILED EXAMINATION: SPECIFIC ANKLEDIAGNOSES

Perform a detailed examination of the thumb if the thumbdemonstrates palpable swelling, nodularity, or synovialthickening. Symptoms have been persistent or chronic.General function is moderately to severely impaired. Earlyjoint contractures have begun to form.

CMC JOINT OSTEOARTHRITIS “My thumb is gettinglarger,” “I can’t grip anymore,” “I get this achy pain in the base ofmy thumb,” “My thumbs used to hurt a lot but now they’re pastthe pain and are just ugly”: All of these patients have osteoarthri-tis of the base of the thumb.


X-RAYS

CASES: Case A is an example of the normal CMCjoint demonstrating a 2-mm articular cartilage widthand a normal alignment with the trapezium.Compare this with the abnormal narrowing and ir-regularities of the articular cartilage of the trapezialnavicular articulation just below the CMC joint.

Case B is an example of advanced osteoarthritis of theCMC joint. The articular cartilage has worn away,the trapezium has lost its saddle shape, and there isa 2- to 3-mm subluxation of the metacarpal bone.

DISCUSSION: The diagnosis of osteoarthritis of theCMC joint can be confirmed with radiographicchanges or by local anesthetic block.

FIGURE 6–9. X-rays to confirm the degree of arthritis of the CMC joint.A B

THUMB 109

POSTTRAUMATIC ARTHRITIS OF THE MP OR IP JOINTOsteoarthritis of the MP joint is uncommon and nearly always re-sults from previous fracture or traumatic injury to the articular

cartilage. The diagnosis is suggested by a combination of history of injury, lateral joint line tenderness, fusiform swelling, and lackof full flexion.

PALPATE THE LATERAL JOINT LINES

SUMMARY: The MP joint is formed by the meta-carpal and proximal phalangeal bones. The jointline is found 1⁄4 inch beyond the distal phalangealhead (knuckle) of the MP joint. The IP joint isformed by the proximal and distal phalangealbones. The joint line is located 1⁄8 inch beyond the distal phalangeal head of the IP joint.

MANEUVER: The lateral joint lines of each joint are palpated for local tenderness, bony enlarge-ment, synovial thickening, and joint swelling.

ADDITIONAL SIGNS: Full flexion is impaired, thejoint may be deviated, and inflammatory signscomplete the examination. The greater the degreeof swelling and deformity, the greater the impair-ment of flexion.

INTERPRETATION: Bony enlargement with minimalsynovial thickening and swelling is characteristicof posttraumatic arthritis. As the condition pro-gresses, the ability to flex the joint is gradually impaired. Inflammatory arthritis can affect thesejoints as well but nearly always occurs as part of a polyarticular involvement.

FIGURE 6–10. Palpate the lateral joint lines for posttrau-matic arthritis.

X-RAYS

CASE: The patient sustained a chip fracture of thethumb 10 years ago while playing baseball. Over theyears the joint ached; more recently it began to swell.The examination demonstrated impaired flexion, bonyenlargement, and early synovial thickening.

DIAGNOSIS: Posttraumatic arthritis of the IP joint. X-rays show a loss of articular cartilage, bony os-teophytes, and sclerotic bone.

DISCUSSION: Most injuries to the small joints of thehand are simple sprains, reversible injuries to thesupporting ligaments and synovial lining. Injury tothe articular cartilage is much less common but canlead to varying degrees of osteoarthritis in subse-quent years.

FIGURE 6–11. X-rays to confirm posttraumatic arthritis of the IP joint.


DE QUERVAIN’S TENOSYNOVITIS “I can’t grip even mypen”; “Every time I lift my baby I feel a sharp pain right here”(pointing to the radial styloid). The diagnosis of de Quervain’s

tenosynovitis is based on these classic descriptions and an examina-tion demonstrating local tenderness directly over the radial styloid.

RADIAL STYLOID PALPATION

SUMMARY: Radial styloid tenderness must be present to make the diagnosis of de Quervain’stenosynovitis. The extensor pollicis longus and brevis and abductor pollicis longus form the outeredges of the anatomic snuffbox. The tendons ofthese muscles become inflamed as they cross theradial styloid to attach to the thumb.


ADDITIONAL SIGNS: Pain aggravated by resistingthumb extension or abduction, pain aggravated by passively stretching the thumb in extension(Finkelstein maneuver), and the presence of cystlike swelling over the distal radius complete the examination.

INTERPRETATION: In the absence of trauma to thedistal radius, radial styloid tenderness coupled withpain aggravated by resisting thumb extension ishighly suggestive of active tenosynovitis.

FIGURE 6–12. Radial styloid palpation for de Quervain’stenosynovitis.


SUMMARY: Local anesthetic block is necessary toconfirm de Quervain’s tenosynovitis and distinguishit from CMC osteoarthritis and conditions affectingthe radiocarpal joint.

POSITIONING: Wrist in neutral position, radial side up.

SURFACE ANATOMY: Styloid process of the radius,the anatomic snuffbox formed by the abductor andextensor pollicis longus tendons, and the proximalmetacarpal.

POINT OF ENTRY: Directly over the radial styloid.

ANGLE OF ENTRY: 45 degrees.



ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL subcuta-neous, 1⁄2 mL at the periosteum of the radial styloid.

FIGURE 6–13. Local anesthetic block to confirm deQuervain’s tenosynovitis.

THUMB 111

TRIGGER THUMB “My thumb hurts in the afternoon, and inthe morning it locks down” is the typical description of the painfultenosynovitis that occurs with repetitive use and the mechanicallocking that results from the tendon swelling.

PALPATION OF THE FLEXOR TENDONS

SUMMARY: The hallmark of flexor tenosynovitis islocal tenderness located over the MP joint on thepalmar aspect of the thumb. The flexor tendons arelocated in the midline and course along the thumbto the base of the middle and distal phalanges.Within the flexor tendon are two sesamoid boneslocated near the first flexor crease.

MANEUVER: The flexor tendons are palpated overthe palmar aspect of the MP joint (arrow).

ADDITIONAL SIGNS: Passive stretching of the flexortendons in extension, the demonstration of clickingor locking at the IP joint, and pain aggravated byresisting flexion (the least common sign) completethe examination.

INTERPRETATION: Active tenosynovitis is diagnosedby demonstrating flexor tendon tenderness at thebase of the metacarpal phalangeal joint combinedwith pain aggravated by passive stretching of thetendon in extension. If the tendon is sufficientlyswollen, it will fail to move freely under the A-1 pul-ley of the tenosynovial sheath, resulting in mechani-cal locking at the IP joint.

FIGURE 6–14. Palpation of the flexor tendons on the pal-mar aspect of the MP joint.


SUMMARY: Local anesthetic block and a positive response to corticosteroid injection are used to confirm the diagnosis of trigger thumb and rule outinvolvement of the underlying MP joint.

POSITIONING: Hand placed flat on the table in thepalm-up position, thumb abducted.

SURFACE ANATOMY: Flexor creases of the thumb,the MP joint, the flexor tendon sesamoid bone, andthe flexor tendon.

POINT OF ENTRY: Directly over the center of thetendon between the flexor creases.



DEPTH: 1⁄8 to 1⁄4 inch, just to the level of the tendon,the first tissue plane.

ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL at the fat–tendon interface with or without 1⁄4 mL depomedrol (D80).

FIGURE 6–15. Local anesthetic block or empirical corticoste-roid injection to confirm trigger thumb.


GAMEKEEPER’S THUMB The middle joint of the thumb—theMP joint—has sustained a torque-like injury; the collateral liga-ment on the ulnar side of the joint has been disrupted. The exami-nation of gamekeeper’s thumb is characterized by local tendernessover the ligament, pain aggravated by valgus stress testing, andvariable degrees of laxity depending on the extent of injury.

VALGUS STRESS TESTING

SUMMARY: Pain aggravated by valgus testing ofthe ulnar collateral ligament of the MP joint of thethumb is needed for the diagnosis of this ligamentinjury. The MP joint is held together by its joint cap-sule, the collateral ligaments, and to a lesser extentthe flexor and extensor tendons that cross the joint.

MANEUVER: The CMC joint and metacarpal boneof the proximal thumb are securely grasped by onehand, and the middle phalanx is firmly grasped bythe other. The examiner presses with two thumbs onthe radial side, applying stress across the ulnar col-lateral ligament.

ADDITIONAL SIGNS: Excessive movement of the ulnar side to the joint defines the higher, second-and third-degree ligament injuries. Degenerative osteoarthritic changes of the MP joint occur late.

INTERPRETATION: The ligament can be strained(pain without abnormal movement), partially torn(pain and increased movement), or completely dis-rupted (pain and unstable joint).

FIGURE 6–16. Valgus stress testing for gamekeeper’s thumb.


SUMMARY: Local anesthetic block is used to distin-guish simple sprain from a torn or avulsed ulnarcollateral ligament. Once adequate pain control is achieved, valgus stress testing can be performed.

POSITIONING: Hand placed flat on the table in thepalm-down position, thumb abducted.

SURFACE ANATOMY: MP joint and joint line.

POINT OF ENTRY: Midplane, directly over the jointline.



DEPTH: 1⁄4 to 3⁄8 inch, just to the level of the liga-ment, the first tissue plane.

ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL at thefat–ligament interface.

FIGURE 6–17. Local anesthetic block to confirm game-keeper’s thumb and determine the degree of ulnar collateral liga-ment injury.

THUMB 113

PAIN REFERRED TO THE THUMB FROM THE CARPALTUNNEL Paresthesia or hypesthesia of the thumb that is unasso-ciated with local tenderness or loss of range of motion of any of thejoints of the thumb suggests either carpal tunnel syndrome or theless common C6 radiculopathy.

TINEL SIGN

SUMMARY: The carpal tunnel is formed by the firstrow of carpal bones (navicular, lunate, pisiform,and triquetral bones) and the transverse carpal liga-ment. It contains nine flexor tendons and the me-dian nerve. Because the Tinel sign is positive inonly 70% of cases, it must be combined with a his-tory of paresthesia or hypesthesia that conforms toa median nerve distribution.


ADDITIONAL SIGNS: The Phelan sign, loss of two-point discrimination of the fingertips, loss of lighttouch and pain sensation, weakness of thumb op-position, and thenar muscle atrophy are the addi-tional signs of median neuropathy.


FIGURE 6–18. Tinel sign to assess carpal tunnel syndrome.


SUMMARY: Local anesthetic block or the responseof symptoms to corticosteroid injection can be usedto identify carpal tunnel syndrome as the primarycause of thumb pain or source of the patient’sparesthesia.

POSITIONING: Wrist in the palm-up position, dorsi-flexed to 30 degrees.

SURFACE ANATOMY: Palmaris longus, pisiformbone, and navicular bone.

POINT OF ENTRY: On the ulnar side of palmarislongus at the most distal volar wrist crease.




ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL in the sub-cutaneous tissue, 1⁄2 to 1 mL beneath the transversecarpal ligament with or without 1⁄2 mL K40.

FIGURE 6–19. Local anesthetic block to confirm medialnerve compression neuropathy (carpal tunnel syndrome).


EXAMINATION SIGNS DIAGNOSIS CONFIRMATION

Pain with anteroposterior compression 1. CMC osteoarthritis Thumb series x-ray, local anesthetic placed at the trapezium of the CMC joint bone

Shelf sign

Swelling at the base of the thumb and the anatomic snuffbox

Crepitation with the mortar and pestle maneuver

Loss of smooth motion of the IP joint Trigger thumb Local anesthetic placed at the flexor tenosynovial sheath (triggering) (optional)

Tenderness over the flexor tendons at the flexor creases in the palm

Pain reproduced by passive extension of the thumb

Pain, stiffness, and incomplete movement Posttraumatic arthritis Thumb series x-ray will be normal with the acute sprain as of the MP or IP joints or sprain of the MP opposed to the narrowed articular cartilage and osteophyte

or IP joints formation seen with posttraumatic arthritis

Palpable swelling along the sides of the joints

Tenderness of the radial styloid De Quervain’s Local anesthetic placed at the radial styloidtenosynovitis

Pain with resisted thumb extension

+ Finkelstein maneuver

Tenderness along the ulnar side of the MP joint Gamekeeper’s thumb Anesthetic placed at the ligament will distinguish simple strainaggravated by valgus stress testing from advanced ligament tears

Swelling in the MP joint

Loss of opposition strength

Hypesthesias or paresthesias by history 2. Carpal tunnel syndrome Medial nerve block with anesthetic or nerve conduction velocitytesting

+Tinel or Phelan sign

Loss of sensation in the first 3 digits

Diminished opposition strength


THUMB 115

TUFF FRACTURE OF THE DISTAL PHALANGES

SUMMARY: Fractures of the distal phalanx are clas-sified as longitudinal, transverse, or crushed-eggshell types. They account for 50% of all handfractures.

IMMOBILIZATION: Simple protective splinting for 3 to 4 weeks using a fingertip guard or Stack splintis combined with specific treatment of the soft tissueinjuries (e.g., laceration, subungual hematoma).The splint should not be placed close to the proxi-mal IP joint so as to avoid joint stiffness.

SURGICAL REFERRAL: Fractures associated with softtissue injuries requiring debridement.

PROGNOSIS: Excellent.

FIGURE 6–21. Tuff fracture of the distal phalanges.

COMMON THUMB FRACTURES AND DISLOCATION

FRACTURE OF THE BASE OF THE METACARPAL

Transverse or oblique fractures of the shafts of themetacarpal (totally extra-articular in all views) canbe treated with closed reduction with good results.The fracture is immobilized for 4 weeks in a well-molded thumb spica cast and followed by passiverange of motion exercises of the thumb. Comminut-ed metacarpal fractures or fractures that involve the CMC joint are inherently unstable and must be managed surgically. A Bennett fracture is a fracture or dislocation of the base of the meta-carpal and is unstable because of the dorsal and radial pull of the abductor pollicis longus. A Rolando fracture is a comminuted fracture of thebase of the thumb and is even more unstable thanthe Bennett fracture. Both fractures should be man-aged by an orthopedic surgeon because of the dif-ficulty in maintaining anatomic reduction without in-ternal pin fixation.

FIGURE 6–20. Fracture of the base of the metacarpal.


DISLOCATION OF THE MP JOINT

SUMMARY: Dislocations of the MP joint occur as aresult of hyperextension injuries (falling or strikingthe end of the thumb). These are classified as in-complete, simple complete, or complex complete.The incomplete is the most common and with thebest prognosis (depicted here). The simple completeis angled at a 90-degree angle. The complex com-plete creates the bayonet deformity.

IMMOBILIZATION: An aluminum metal splint is usedfor 3 weeks for the incomplete injuries.

SURGICAL REFERRAL: Ligament and volar plate in-juries are more complicated with the simple com-pete and complex complete types and should beevaluated by the hand surgeon.

PROGNOSIS: The prognosis is guarded. Late-onsetosteoarthritis and recurrent dislocations are the rulefor the more advanced injuries.

FIGURE 6–22. Dislocation of the MP joint.

DISLOCATION OF THE IP JOINT

SUMMARY: Simple dislocation without significant in-jury to the articular cartilage or the supporting liga-ments has a uniformly good prognosis. Dislocationwith permanent damage to the cartilage or the sup-porting ligaments can cause an accelerated wearpattern leading to osteoarthritis years later.

Mallet thumb results from a rupture of the extensorpollicis longus insertion. Treatment with IP jointsplinting and operative repair provides similar results.

FIGURE 6–23. Dislocation of the IP joint can lead to os-teoarthritic changes years later.

THUMB 117

• Osteoarthritis of the CMC joint is a universal problem,developing to some degree in nearly everyone over age60. Fortunately, only 5% to 10% develop arthritic flares,consisting of pain and loss of function.

• The examination of a sprained CMC joint overlapswith that of the examination of the osteoarthritic joint.The pain and lateral joint line tenderness and the softtissue swelling are identical. However, the simple sprainlacks bony enlargement, subluxation, and the x-raychanges demonstrating arthritic changes.

• In the absence of direct trauma, soft tissue swelling thatfills the anatomic snuffbox probably is caused by a se-verely sprained or osteoarthritic CMC joint.

• Local anesthetic block is necessary to distinguish deQuervain’s tenosynovitis from an arthritic flare of theCMC joint; the pain pattern, impairment of thumb

CLINICAL PEARLS

function, and abnormal signs on examination overlapgreatly. Note that the Finkelstein maneuver (stretchingthe extensor and abductor tendons of the thumb whilepassively moving the wrist in ulnar deviation) can be pos-itive in either condition; a positive maneuver is not syn-onymous with de Quervain’s tenosynovitis.

• Examination of the acutely injured gamekeeper’sthumb alone cannot distinguish the simple sprain fromthe more advanced torn ligament. Local anestheticblock is necessary to control the patient’s pain, allowingproper valgus stress testing.

• Although the mechanisms causing the loss of smoothmovement are similar, the mechanical symptom of trig-ger thumb (locking at the IP joint) is distinct from thatof the trigger finger (locking at the proximal IP joint).

AVULSION OF THE LATERAL COLLATERALLIGAMENT OF THE MP JOINT

SUMMARY: Avulsion of the lateral collateral liga-ment of the MP joint is analogous to gamekeeper’sthumb. The injury is staged as simple, partiallytorn, or completely torn with or without avulsionfracture. Local anesthetic block is used to distin-guish the simple sprain from a torn or avulsed lat-eral collateral ligament. Once adequate pain con-trol is achieved, varus stress testing can beperformed. Simple and partially torn ligaments canbe managed with 3 weeks of fixed immobilization(dorsal hood splint, thumb spica cast, or Velcrothumb spica splint). Complete tears should be eval-uated by the hand surgeon.

FIGURE 6–24. Avulsion of the lateral collateral ligamentof the MP joint.

118

CHAPTER 7: HAND


Diagnoses

Osteoarthritis (most common)Heberden’s and Bouchard’s nodesPosttraumatic monoarticular osteoarthritisMucinoid cysts atop the jointErosive subtype of osteoarthritis

Rheumatoid arthritis

Flexor tendonsTrigger finger or flexor tenosynovitisFixed locked digitTendon cystBenign giant cell tumor

Palmar fasciaPalmar fibromatosis without contractureDupuytren’s contractureLimited joint mobility syndrome

(in long-standing diabetes)

Posttraumatic metacarpophalangeal joint arthritis

Extensor tendonsMallet fingerCarpal tunnelCervical radiculopathy

Reflex sympathetic dystrophy

Confirmations

Examination, x-rays: hand seriesExamination, x-rays: hand seriesExamination, simple punctureX-ray: hand series

Synovial fluid analysis, erythrocyte sedimentationrate, rheumatoid factor (RF)

ExaminationExaminationExamination, simple punctureSurgical removal, pathology

ExaminationExaminationExamination

Examination, local anesthetic block, x-rays

ExaminationNerve conduction velocity, local anesthetic blockCervical series, magnetic resonance imaging,

electromyographyExamination, bone scan

HAND 119

INTRODUCTION The conditions occurring in thehand can be conveniently divided into diagnoses affectingthe joints (the arthritides), the tendons (injuries and ten-donitis), and the peripheral nerves (carpal tunnel and ulnarneuropathy). The arthritides are further classified based onthe number of joints affected, the distribution of the af-fected joints, and the degree of inflammation. The condi-tions affecting the tendons are classified based on type(flexor or extensor tendons injuries), acuity of the process,and mechanism of injury.

Multiple joint involvement in the hands is caused mostoften by osteoarthritis, rheumatoid arthritis, or psoriatic in-flammatory arthritis. Osteoarthritis is by far the most com-mon form of arthritis affecting the hands. This wear-and-tear arthritis is characterized by bony enlargement of thelateral aspects of the joint, modest swelling, and gradual lossof range of motion and deformity. With age-related os-teoarthritis the distal interphalangeal joints (DIPs) are af-fected preferentially, with lesser involvement of the proxi-mal interphalangeal joints (PIPs); metacarpophalangeal(MCP) or wrist joint involvement is unusual. Secondarycomplications include bony ankylosis, fixed deformity, andmucinoid cyst formation atop the dorsal aspect of the joint.

By contrast, rheumatoid arthritis, the quintessential in-flammatory arthritis, is characterized by soft, fusiformswelling of the joints, moderate loss of range of motion, andmoderate to severe inflammatory changes. Involvement ofthe PIP joints, the MCP joints, and the wrists predominates;DIP joint involvement is unusual, with the exception ofpsoriatic arthritis. A symmetrical pattern of joint distribu-tion is the rule. Secondary complications consist of ulnardeviation, especially at the MCP joints and wrist, swan neckdeformities of the DIP joints, boutonnière deformities ofthe PIP joints, and dorsal tendon rupture.

Single joint involvement in the hands is almost alwaysthe result of previous and often remote trauma. Post-traumatic arthritis is characterized by bony enlargement,modest swelling, gradual loss of range of motion, and jointdeformity. The DIP joints are most susceptible to injury, fol-lowed by the PIP and MCP joints.

Because gripping and grasping are the dominant func-tions of the hand, it follows that repetitive and unaccus-tomed use leads to injury and inflammation of the flexortendons. Direct pressure over the palm, especially over theheads of the distal MCP joints, leads to the acute swellingand pain (flexor tenosynovitis), loss of smooth motion(mechanical locking or triggering), loss of function (thefixed locked digit), and cystic degeneration of the tendon(tendon cyst formation). Chronic pressure over the flexortendons of the palm leads to the gradual scarring of the pal-mar fascia (palmar fibrosis or Dupuytren’s contracture).

By contrast, the extensor tendons of the hand are moresusceptible to traumatic injury rather than overuse or pres-sure. Damage to the profundus extensor tendon causes mal-let finger. Damage to the central slip of the extensor tendoncombined with tearing of the triangular ligament on thedorsum of the middle phalanx causes the acute bouton-nière deformity.

Diffuse hand pain typically accompanied by hypesthesiaor paresthesia can be caused by carpal tunnel, cervicalradiculopathy, brachial plexopathy, or reflex sympatheticdystrophy. The particular diagnosis usually is obvious based

on the associated symptoms and signs at the wrist, neck, orshoulder, respectively.

SYMPTOMS Conditions directly affecting the joints andsoft tissues of the hand cause a loss of general function (re-duced gripping, grasping, and pinching), pain, swelling, de-formity, stiffness, loss of range of motion, or a combinationof these symptoms. In general, multiple joint involvementprobably is the result of osteoarthritis or a generalizedrheumatologic condition. Involvement of one or two digitsor joints suggests a focal soft tissue condition.

Pain, stiffness, and bony enlargement of multiple DIPjoints suggest the common, wear-and-tear osteoarthritis thataccompanies aging. Bony enlargement rather than synovialthickening or swelling is the key physical finding when onepalpates the lateral joint lines.

Pain, swelling, and fusiform enlargement of multiplehand joints is the classic presentation of an inflammatoryarthritis. Involvement of the DIP joints is seen with psori-atic arthritis. Involvement of the PIP and MCP joints is seenwith rheumatoid arthritis. Compressible synovial thickeningand swelling are the key physical findings when one palpatesthe lateral joint lines.

Localized tenderness over a single MCP joint in thepalm with or without the loss of smooth motion of the digitis the classic physical finding of flexor tenosynovitis.Persistent inflammation causes the tendon to graduallyswell, preventing the smooth motion of the two flexor ten-dons under the A-1 pulley of the tenosynovial sheath.Mechanical symptoms of clicking or trigger phenomenonresult. Tendon cysts and Dupuytren’s contracture present aspainless nodules that form in or along the flexor tendons inthe palm. A firm nodule located adjacent to a single MCPjoint is characteristic of a benign tendon cyst. Despite theirsize, these rarely interfere with the function of the digit orhand. By contrast, multiple nodules adjacent to severalMCP joints in the palm are characteristic of Dupuytren’scontracture. This progressive scarring of the palmar fascia af-fects finger function, gradually interfering with the ability tofully extend of the digit.

Mallet finger presents as a characteristic deformity aftertrauma. Pain is rarely a significant issue after the initial in-jury heals.

Pain localized to the dorsum of a single MCP joint typ-ically is caused by posttraumatic arthritis.

Finally, the examination of the hand is completed with ascreening maneuvers of the medial nerve for signs of carpaltunnel syndrome.

EXAMINATION Examination of the hand begins withan assessment of active function (gripping, grasping, andpinching) and range of motion testing of all 17 joints. Thesemaneuvers combine to provide an objective measurementof function, a preliminary assessment of the severity of thecondition, and important clues to the specific diagnosis.

Next, specific maneuvers for each diagnosis are per-formed based on the location and description of the painand the clues provided by the functional screening tests.Pain, stiffness, and bony deformity of the DIP or PIPjoints are the characteristic signs of the common age-related


arthritis (osteoarthritis). Pain, stiffness, and synovialswelling of the PIP or MCP joints are the characteristicsigns of inflammatory arthritis, with rheumatoid arthritis be-ing the most common form.

Pain and local tenderness located directly over theflexor creases in the palm are characteristic of a flexor ten-don cyst or active flexor tenosynovitis (trigger finger).Locking or clicking of the PIP joint or a loss of the normalsmooth motion of the PIP joint with active flexion indicatetrigger finger.

Painless thickening of the palm associated with impairedextension of the affected digit is the classic finding ofDupuytren’s contracture. This must be distinguished fromthe swelling that occurs in an isolated tendon; tendon cystsoccur at the base of the digit rather than in the central areaof the palm.

Pain and swelling over an isolated MCP joint are typicalfor posttraumatic osteoarthritis. Symmetrical involvementof several MCP joints is seen with inflammatory arthritis.

Swelling over the extensor aspect of the DIP joint is spe-cific for a mucinoid cyst.

Painless loss of extension of the DIP joint is the charac-teristic abnormality of mallet finger, or traumatic rupture ofthe distal extensor tendon.

Paresthesia or hypesthesia of selected fingers is character-istic of compression neuropathy. Sensory loss of some com-bination of the first three fingers is the classic distributionof carpal tunnel syndrome. Sensory loss of the fourth andfifth fingers is the classic distribution of ulnar neuropathy.Loss or abnormal sensation affecting all fingers simultane-ously can be caused by hyperventilation (if bilateral),brachial plexus lesions, multilevel spinal stenosis, peripheralneuropathy, or the rare combination of ulnar and medialnerve compression neuropathies.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL HAND FUNCTION

The next six maneuvers represent the minimal examinationof the patient presenting with hand symptoms. Range ofmotion measurement and screening maneuvers for osteo-arthritis, Dupuytren’s contracture, trigger finger, and carpaltunnel syndrome provide enough information to triage to x-ray, order appropriate labs, suggest general treatment rec-ommendations, or proceed to more detailed examinationand treatment.

1. Observe the general movement of the hand joints(opening and closing the fist).

2. Estimate or measure grip strength (dynamometricmeasurements).

3. Inspect the DIP, PIP, and MCP joints for swelling,synovial thickening, and bony enlargement.

4. Examine the flexor and extensor tendons for inflam-mation, nodules, or nodular thickening.

5. Perform screening tests for carpal tunnel syndrome.

ESSENTIAL EXAMINATION OF THE HANDBOX 7-1

GRIPPING AND GRASPING

SUMMARY: Full function of the hand requires thenormal function of the MCP, PIP, and DIP joints onall four fingers, intact flexor and extensor tendons,and an intact recurrent median nerve and ulnarnerve.

MANEUVER: The patient is simply asked to openand close the fist while the examiner notes the pa-tient’s ability to actively flex and extend the MCP,PIP, and DIP joints of each finger and thumb.

INTERPRETATION: Arthritis from any cause or anycondition affecting the flexor tendons (finger andDupuytren’s contracture) or the extensor tendons(mallet finger and dorsotenosynovitis) can impairoverall hand function.

FIGURE 7–1. Gripping and grasping to assess overall handfunction.

HAND 121

MANUAL GRIP STRENGTH MEASUREMENT

SUMMARY: Grip strength measurement is the mostobjective, albeit indirect, measurement of the in-tegrity and strength of the intrinsic and supportingmuscles of the hand. Gripping can be influencedby arthritis of the intrinsic joints of the hands, intrin-sic muscles of the hand, and flexor and extensortendons.

MANEUVER: Grip strength can be crudely estimatedby manual gripping of the examiner’s fingers.However, physical measurement using a dy-namometer is much more accurate and repro-ducible. An alternative method involves compress-ing a partially inflated blood pressure cuff.

INTERPRETATION: Grip strength is reduced in a consistent manner by disuse atrophy, hand arthritis,carpal tunnel syndrome, severe tenosynovitis,Dupuytren’s contracture, and C8 cervical radicu-lopathy. Inconsistent measurement of grip strength is seen with malingering.

FIGURE 7–2. Manual grip strength measurement.


SUMMARY: Grip strength measurement is the mostobjective, albeit indirect, measurement of the in-tegrity and strength of the intrinsic and supportingmuscles of the hand. Gripping can be influencedby arthritis of the intrinsic joints of the hands, intrin-sic muscles of the hand, and flexor and extensortendons.

MANEUVER: The average of three consecutive read-ings using the dynamometer provides an accurateand reproducible measurement of gripping andforearm muscle strength. An alternative method in-volves compressing a partially inflated blood pres-sure cuff (see Figure 7-2).

INTERPRETATION: Grip strength is reduced in a consistent manner by disuse atrophy, hand arthritis,carpal tunnel syndrome, severe tenosynovitis,Dupuytren’s contracture, and C8 cervical radicu-lopathy. Inconsistent measurement of grip strength is seen with malingering.

FIGURE 7–3. Grip strength measurement.


INSPECT THE SMALL JOINTS OF THE HAND

SUMMARY: The DIP, PIP, and MCP joints, the exten-sor tendons, and the intrinsic muscles of the handare readily inspected with the palms down.

MANEUVER: The hands are inspected for alignment,fusiform swelling, bony enlargement, joint deformityincluding ankylosis and contracture, and the pres-ence of cysts or nodules in the palms-down position.

INTERPRETATION: Osteoarthritis affects the DIP and PIP joints, producing bony enlargement, mildswelling, and deformity. Rheumatoid arthritis af-fects the PIP and MCP joints and is characterizedby fusiform swelling in a symmetrical pattern andnormal alignment. Atrophy of the intrinsic musclesof the hand occurs with chronic arthritis andchronic C8 cervical radiculopathy.

FIGURE 7–4. Inspect the small joints of the hand forswelling, bony enlargement, and deformity.

INSPECT THE PALM

SUMMARY: The flexor tendons of the hand are cov-ered by a tenosynovial sheath, which in turn is cov-ered by a thick palmar fascia. Abnormal thickeningof this fascia is called palmar fibromatosis.

MANEUVER: The position of each of the four fingersis noted (incomplete extension of the fifth fingers is depicted here). All four fingers are passivelystretched in full flexion, followed by passive stretch-ing in extension.

INTERPRETATION: Lack of full extension typically is caused by the nodular thickening of the palmar fascia. Several discrete nodules can be palpatedalong the course of the flexor tendons in the palm.Single ganglion cysts arising from the tenosynovialsheaths typically do not restrict full extension of thefingers.

FIGURE 7–5. Inspect the palm for swelling, tendon thicken-ing, and deformity.

HAND 123


TRIAGE TO X-RAY The patient has a history of trauma,the exam demonstrates osteoarthritic bony enlargement orjoint swelling, rheumatoid arthritis is suspected, or the pa-tient is at risk for reflex sympathetic dystrophy:

• Order three views of the fingers for patients with a historyof hyperextension injuries, crush injuries, or a direct blow(ligament injury due to dislocation, phalangeal fracture,tendon avulsion, or tuft fracture).

• Order arthritic views of both hands for patients with sus-pected arthritis (osteoarthritis, rheumatoid arthritis, orpsoriatic arthritis).

• Order a posteroanterior view of both hands for patientswith diffuse hand pain, swelling, and discoloration (reflexsympathetic dystrophy).

• Order a carpal tunnel view for patients with wrist traumaand acute median nerve loss (perilunate dislocation andacute carpal tunnel syndrome).

TRIAGE TO THE LAB For patients with acute inflam-matory arthritis or patients with recent penetrating injuryand acutely inflamed joint:

• Order a complete blood cell count, erythrocyte sedimen-tation rate, and C-reactive protein for patients with acutepain, swelling, and signs of active inflammation (inflam-matory arthritis).

• Order a complete blood cell count, erythrocyte sedimen-tation rate, and blood cultures for patients with acute in-flammatory changes and significant fever.

CONSIDER A BONE SCAN For patients with diffusehand pain, swelling, and discoloration (reflex sympatheticdystrophy).

CONSIDER A NERVE CONDUCTION VELOCITYTEST For patients with advanced carpal tunnel symptomsinvolving motor weakness and atrophy.

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate hand pain and stiffness, unim-paired gripping and grasping, normal joint alignment, andno contractures or deformities:

• Avoid repetitious gripping and grasping.• Avoid all vibration exposure.• Avoid prolonged contact with cold.• Wear thick leather gloves for protection.• Apply direct heat (wax treatments in a crock pot).• Perform gentle range of motion exercises in flexion and

extension to prevent contractures.

DETAILED EXAMINATION: SPECIFIC HANDDIAGNOSES

Perform a detailed examination of the hand if the joints ofthe hand demonstrate palpable swelling, nodularity, or syn-ovial thickening. Symptoms have been persistent orchronic. Overall hand function is moderately to severelyimpaired, or early joint contractures have developed.

TINEL SIGN COMBINED WITH A COMPATIBLEHISTORY

SUMMARY: The carpal tunnel is formed by the firstrow of carpal bones (navicular, lunate, pisiform, and triquetral) and the transverse carpal ligament. It contains nine flexor tendons and the mediannerve. Because the Tinel sign is positive in only70% of cases, it must be combined with a historyof paresthesia and hypesthesia that conforms to the median nerve distribution.


INTERPRETATION: For the Tinel sign to be consid-ered positive, the patient’s pain must be repro-duced and the paresthesia should be distinctly dif-ferent from the response on the contralateral side.

FIGURE 7–6. Tinel sign combined with a compatible his-tory to screen for carpal tunnel syndrome.


OSTEOARTHRITIS OF THE HAND Osteoarthritis of thehand is characterized by bony enlargement of the DIP and PIPjoints (Heberden’s and Bouchard’s nodes). It is one of the most

common forms of arthritis, and most patients complain moreabout the bony deformity and unattractive appearance than thepain or loss of function.

PALPATE THE BONY ENLARGEMENT

SUMMARY: As the articular cartilage graduallywears down, the body responds by forming osteo-phytes along the joint margins. These hard bonyprominences are called Heberden’s nodes at theDIP joints and Bouchard’s nodes at the PIP joints.As the process continues, the joint gradually losesrange of motion.

MANEUVER: After the hands are inspected, individ-ual joints are palpated along the joint lines forbony enlargement, synovial thickening, andswelling.

ADDITIONAL SIGNS: Mucinoid cysts may be pre-sent on the dorsum of the DIP joints. Advancedarthritis leads to deformity and loss of full flexion.

INTERPRETATION: The bony enlargement along thelateral joint lines readily distinguishes osteoarthritisfrom rheumatoid arthritis. The severity of the pro-cess is determined by the bony enlargement andthe effect on joint alignment and on the ability tofully flex the fingers.

FIGURE 7–7. Palpate the bony enlargement of the DIPjoints.

X-RAY OF THE HANDS

CASE: The patient has had painful hands with thegradual loss of the fine motor skills over the last 20years. The family history is remarkable for arthritis.Examination of the hands demonstrates bony en-largement of the DIP and PIP joints with very littlepalpable swelling or thickening. Range of motion is severely limited, especially at the DIP joints; thepatient is unable to make a complete fist. X-raysdemonstrate complete loss of articular cartilage,large bony osteophytes, and ankylosis. The middlefinger is especially affected.

DIAGNOSIS: Advanced osteoarthritis of the hands.

DISCUSSION: Osteoarthritis of the hands is a clini-cal diagnosis. X-rays usually are not necessary toconfirm the diagnosis. However, X-rays are indi-cated when inflammatory arthritis is suspected.

FIGURE 7–8. X-ray of the hands to confirm the degree of os-teoarthritic wear and tear.

HAND 125

RHEUMATOID ARTHRITIS Of the five forms of rheumatoidarthritis (classic, monarthritic, pauciarticular, systemic, and palin-dromic), only the classic form consistently affects the hands.

Classic rheumatoid arthritis is characterized by loss of full grip,morning stiffness, symmetrical joint swelling of the PIP and MCPjoints, and boggy synovial thickening.

PALPATION

SUMMARY: The synovial lining of the small joints of the hand extends 5 to 6 mm above and below the joint line. Excessive amounts of joint fluid causethe characteristic fusiform shape.

MANEUVER: The examiner places two fingers ofone hand on the lateral joint lines and two fingersfrom the opposite hand on the top and bottom of the joint. The examiner applies pressure from the top and bottom while palpating the joint for synovial thickening and excessive joint fluid. The maneuver can be enhanced by alternating the pressure from one set of fingers to the other.

ADDITIONAL SIGNS: Measurement of grip strengthis always impaired with active disease. The MCP,wrists, and intrinsic joints of the feet may be in-volved. Advanced cases may show the palpablepurpura of vasculitis.

INTERPRETATION: Inflammatory arthritis is character-ized by swelling and synovial thickening, as op-posed to the bony enlargement and deformitycaused by osteoarthritis.

FIGURE 7–9. Palpation of the PIP joint synovial thickening ofinflammatory arthritis.

X-RAY OF THE HANDS

CASE: The patient has a long history of psoriaticarthritis. Fusiform swelling of the PIP and DIP joints is noted on physical examination. X-rays of thehands demonstrate mild osteoarthritic changes atthe DIP joints and inflammatory changes at the DIPand PIP joints. Large erosive changes are particu-larly notable at the DIP joints of the index and mid-dle fingers (arrows).

DIAGNOSIS: Psoriatic arthritis of the IP joint.

DISCUSSION: X-rays of the hands of patients withinflammatory arthritis often are normal in the earlystages of the disease. Juxta-articular osteoporosis, reflecting the increased blood flow to the joints, is the earliest radiographic finding. Late findings in-clude symmetrical wear of the articular cartilage,generalized osteopenia, erosive changes, angula-tion, and ankylosis.

FIGURE 7–10. X-ray of the hands to evaluate the severity ofinflammatory arthritis.


MCP SQUEEZE SIGN

SUMMARY: The MCP joints are formed by the distal metacarpal bones and the proximal pha-langes. When a fist is made, the joint lines are located 1⁄4 to 3⁄8 inch from the center of the knuckle(the distal metacarpal head). Rheumatoid arthritiscommonly affects the MCP joints in a symmetricalpattern.

MANEUVER: With one hand placed over the middleof the metacarpal bones to hold them in line, theexaminer applies pressure across the second andfifth metacarpal heads, forcing all four metacarpaljoints together.

ADDITIONAL SIGNS: Grip strength is impaired with ac-tive involvement of the MCP joints. Swelling may oblit-erate the normal hills and valleys between the knuckles.Advanced disease may show ulnar deviation.

INTERPRETATION: Posttraumatic arthritis of the MCPis the likely diagnosis if a single joint is involved.Multiple joint involvement is almost always an indi-cation of active rheumatoid arthritis.

FIGURE 7–11. MCP squeeze sign to assess the involvement ofthe MCP joints.

DECREASED AND PAINFUL LOSS OF RANGEOF MOTION

SUMMARY: Bilateral wrist involvement is characteris-tic of the classic form of rheumatoid arthritis. As thecondition progresses, the wrists become painful,swell, and subsequently lose full range of motion.

MANEUVER: With one hand grasping the forearm,the examiner passively flexes and extends thewrist, noting the patient’s pain, the tendency to resist the maneuver, the degree of endpoint stiff-ness, and the range of motion, measured in de-grees of flexion and extension (normal range ofmotion is 90 degrees of flexion, 80 degrees of extension, and approximately 45 degrees of radial and ulnar deviation).

ADDITIONAL SIGNS: With advanced disease thewrist gradually drifts into ulnar deviation.

DIFFERENTIAL DIAGNOSIS: Rheumatoid arthritiscan present in innumerable ways. The symmetricalinvolvement of the PIPs, MCPs, and wrist is the clas-sic pattern.FIGURE 7–12. Decreased and painful loss of range

of motion suggest involvement of the wrist.

HAND 127

TRIGGER FINGER Minor trauma and repetitive gripping andgrasping compress the flexor tendons as they course over the MCPhead in the palm. This pressure and friction cause the tendon togradually swell within the unyielding tenosynovial sheath, an in-

flammatory reaction that leads to a loss of smooth motion of thetendons under the A-1 pulley of the tenosynovial sheath. The diag-nosis can be made by identifying active tenosynovitis or by docu-menting the mechanical triggering phenomenon.

MECHANICAL DYSFUNCTION

SUMMARY: Smooth motion of the finger requires the free movement of the two flexor tendonsthrough the tenosynovial sheath.

MANEUVER: The hands are placed in the palms-upposition, and the patient is asked to flex and extendthe fingers. Alternatively, if active triggering is notpresent, the examiner places his or her fingers onthe PIP joint as the finger is actively flexed and ex-tended, noting the loss of smooth motion or a click-ing sensation.

ADDITIONAL SIGNS: Passive stretching of the fingeris painful with active tenosynovitis. Less commonly,resisting finger flexion isometrically is painful. A small percentage of patients have a palpablenodule in the flexor tendon located over the MCPhead.

INTERPRETATION: The three stages of trigger fingerare active tenosynovitis, mechanical triggering, andthe fixed locked digit.FIGURE 7–13. Mechanical dysfunction (triggering or click-

ing) of trigger finger.

LOCAL ANESTHETIC BLOCK OVER THE FLEXORTENDON

SUMMARY: Swelling of the flexor tendons (tenosyn-ovitis) always precedes the mechanical locking oftrigger finger. Left untreated, the triggering phenom-enon can persist and cause the fixed locked digit.

POSITIONING: Hand flat, palm-up position, fingersextended.

SURFACE ANATOMY: Flexor tendon, metacarpalhead, and proximal finger crease.

POINT OF ENTRY: Over the metacarpal head, prox-imal to the finger crease.




ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL subcuta-neous, 1⁄4 mL at the flexor tendon.

FIGURE 7–14. Local anesthetic block placed over theflexor tendon to confirm the tenosynovitis accompanying triggerfinger.


TENDON CYST Intratendon and peritendinous cysts typicallyare pea-sized nodules located in or adjacent to the flexor tendonsin the palm. Minor trauma or repeated heavy pressure over the

MCP joints incites excessive production of the tenosynovial fluid.In contrast to the mechanical locking of trigger finger, active andpassive movement of the digit is unimpaired.

PALPATION

SUMMARY: The majority of tendon cysts occurwithin a centimeter of the flexor crease of the palm.On average, they are pea-sized and firm to hard inconsistency.

MANEUVER: With the hand placed palm up andthe fingers extended, the flexor tendon is palpatedalong its entire course from DIP joint to the palm.Passive movement of the finger is performed to de-termine whether the cyst moves with the finger (in-tratendinous) or independently of it (peritendinous).

ADDITIONAL SIGNS: Finger movement should benormal. Inflammatory reactions are unusual.

INTERPRETATION: The tendon cyst is sensitive to di-rect pressure. Active tenosynovitis (pain aggravatedby passive stretching or isometrically resisted flex-ion) is unusual.

FIGURE 7–15. Palpation of the flexor tendon for tenderness orcyst formation.

SIMPLE PUNCTURE

SUMMARY: Tenosynovial cysts are located withinthe tendon or adjacent to it. Minor injury to the tendon leads to an overproduction of tenosynovialfluid.

POSITIONING: Hand flat, palm-up position, fingersextended.

SURFACE ANATOMY: Flexor tendon, metacarpalhead, and proximal finger crease.

POINT OF ENTRY: Over the metacarpal head, prox-imal to the finger crease.




ANESTHESIA: Ethyl chloride, skin: 1⁄4 mL subcuta-neous, 1⁄4 mL at the flexor tendon.

FIGURE 7–16. Simple puncture to confirm the benigntenosynovial cyst.

HAND 129

DUPUYTREN’S CONTRACTURE Dupuytren’s contracture isa progressive fibrosis of the flexor tendons in the palm. Painless,palpable nodules (palmar fibrosis) most commonly form over the

fourth and fifth flexor tendons. Although it is associated with alcoholic cirrhosis, the majority of cases (95%) are inherited; patients of northern European descent are at greater risk.

SIMPLE INSPECTION OF THE PALM

SUMMARY: The two flexor tendons course throughthe palm to attach to the middle phalanges (super-ficialis tendon) and to the distal phalanges (profun-dus tendon) of each finger. The tendons are en-veloped by a tenosynovial sheath, which in turn is covered by the thick palmar fascia.

MANEUVER: The hands are placed in the palms-up position. Each of the four digits is passivelystretched in extension, and the examiner notes anydifferences in flexibility and any palmar scarring.Triangular puckering at the base of the finger maybe the only sign of early palmar scarring. Next, thetendons are palpated for thickening or nodularityalong their course through the palm.

ADDITIONAL SIGNS: None.

INTERPRETATION: Loss of full extension is the func-tional consequence of Dupuytren’s contracture.Clicking, catching, and triggering, as with trigger finger, do not occur with this pathologic scarringprocess.

FIGURE 7–17. Simple inspection of the palm is used to di-agnose advanced Dupuytren’s contracture.

PASSIVE EXTENSION OF THE FINGER AND PALPATION

SUMMARY: Most cases of Dupuytren’s contracturego unnoticed for years. The earliest finding is apuckering of the skin in the palm when attemptingto stretch the fingers passively in extension. Thisearly scar formation limits extension during passivemovement of the fingers.

MANEUVER: The hands are placed in the palms-upposition. Each of the four digits is passively stretch-ed in extension, and the examiner notes any differ-ences in flexibility and any palmar scarring.Triangular puckering may be the only sign of earlypalmar scarring. Next, the tendons are palpatedfor thickening or nodularity along their coursethrough the palm.

FIGURE 7–18. Passive extension of the finger and pal-pation of the palmar fascia for nodularity are used to detect theearly stage of palmar fibrosis.


TRAUMATIC ARTHRITIS OF THE MCP JOINT Months to years after a substantial injury to the articular cartilage of themetacarpal joint (e.g., direct blow, fist injury, crush), an acceler-ated wear-and-tear arthritis develops. On examination, the MCP

squeeze sign is painful, and the involved MCP joint fails to fullyflex. As the condition progresses, x-rays will confirm greater de-grees of articular cartilage wear, osteophyte formation, and scle-rotic bone formation.

MCP JOINT SWELLING

SUMMARY: The distal metacarpal heads articulatewith the proximal heads of the phalanges to formthe MCP joints. Swelling of these joints obliteratesthe impression formed between the MCP joints (i.e., the hills and valleys of the knuckles are lost).

MANEUVER: The patient is asked to make a partialfist, and the MCP joints are inspected for swelling.

ADDITIONAL SIGNS: Substantial swelling impairsthe ability to fully flex the MCP joints. Grip is im-paired by pain. The MCP squeeze sign is painful.

DISCUSSION: Single MCP joint involvement usuallyis due to previous trauma (monarthritic traumaticarthritis). Symmetrical involvement of multiple MCPjoints is characteristic of inflammatory arthritis, par-ticularly rheumatoid arthritis.FIGURE 7–19. MCP joint swelling.

LOCAL ANESTHETIC

SUMMARY: Isolated involvement of a single MCPjoint usually follows bony fracture or injury to thearticular cartilage. Often the seemingly minor injurygoes unnoticed because symptoms develop months or even years later.

POSITIONING: Wrist flat on the table, palm sidedown.

SURFACE ANATOMY: Metacarpal heads, webspace, extensor tendons.

POINT OF ENTRY: In the web space between themetacarpal heads.





FIGURE 7–20. Local anesthetic is placed adjacent to the MCPjoint to confirm involvement of the joint.

HAND 131

MALLET FINGER Mallet finger is the deformity associatedwith the complete detachment of the extensor longus tendon from

the base of the distal phalanx. The diagnosis is based on the char-acteristic deformity and the loss of full extension of the DIP joint.

INSPECTION

SUMMARY: The profundus tendon attaches to thebase of the distal phalanges just past the joint lineof the DIP joint.

MANEUVER: The affected finger is grasped withone hand and the finger of the second hand isplaced atop the distal phalanges. The patient isasked to actively extend the DIP joint.

ADDITIONAL SIGNS: None.

DISCUSSION: Direct blows to the tip of the ex-tended finger are the most common mechanism of tendon rupture.

FIGURE 7–21. Inspection of the finger deformity caused by arupture of the distal extensor tendon.

X-RAYS

CASE: The patient sustained an acute injury whileplaying basketball. Initially, the symptoms were too acute for a full examination of the finger. In thefollow-up period, the patient was unable to fully re-sist extension of the distal phalanx.

DIAGNOSIS: Avulsion fracture accompanying therupture of the extensor profundus tendon, leadingto the mallet finger deformity.

DISCUSSION: The mallet finger deformity can resultfrom stretching or partial tearing of the extensortendon, complete rupture, or rupture with avulsionfracture of the distal phalanx. Treatment consists ofsplinting the DIP joint in full extension or slight hy-perextension for 1 to 2 months, using a dorsal alu-minum splint and tape or a Stack splint. The patientshould be advised that function may be impaired inup to 30% of cases, especially in patients over age60, in patients with rheumatoid arthritis or periph-eral vascular disease, if treatment is delayed morethan 4 weeks, or if immobilization lasts fewer than 4 weeks. Patients with large avulsion fracturesshould be evaluated by an orthopedic surgeon.

FIGURE 7–22. X-rays to confirm the rupture of extensor profun-dus, leading to the mallet deformity.


MUCINOID CYST OF THE DIP JOINT Mucinoid cysts re-sult from the excessive production and subsequent leakage of syn-ovial fluid from osteoarthritic DIP or PIP joints. The fluid leaks

out of the small synovial cavity into the subcutaneous tissues,forming 4- to 5-mm diameter, faint gray cysts. Simple puncturedemonstrates the highly viscous synovial fluid.

INSPECTION

SUMMARY: Arthritic DIP or PIP joints that are ex-posed to repetitious use or prolonged vibration pro-duce excessive amounts of lubricating synovialfluid. Because the synovial cavity is limited in sizeand distensibility, some of the excessive fluid leaksinto the subcutaneous tissue; then, the body isolatesthe fluid by forming a cyst.

MANEUVER: The size, shape, and compressibility of the cyst are determined by physical measurementand palpation.

ADDITIONAL SIGNS: The underlying osteoarthriticchanges are always detectable by exam or x-ray.

DIFFERENTIAL DIAGNOSIS: Herpetic whitlows andsubcutaneous abscesses are red, hot, and swollen.The fibrosis that accompanies foreign body reac-tions and dermatofibromas are firm to hard in con-sistency, as opposed to the cystic quality of the mu-cinoid cyst.

FIGURE 7–23. Inspection of the dorsum of the hand for muci-noid cysts.

SIMPLE PUNCTURE

SUMMARY: Mucinoid cysts result from an overpro-duction of synovial fluid from an arthritic DIP. Fluidin this small-capacity joint leaks into the subcuta-neous tissues, forming a 4- to 6-mm diameter cyst.

POSITIONING: Finger flat and fully extended.

SURFACE ANATOMY: Cyst, DIP joint, and nail bed.

POINT OF ENTRY: At the base of the cyst.


NEEDLE: 5⁄8 inch, 25 gauge or 1 inch, 22 gauge.

DEPTH: Superficial.

ANESTHESIA: Ethyl chloride is sprayed on the skin.1⁄4 cc of local anesthetic is placed just under theskin.

FIGURE 7–24. Simple puncture to confirm the benign natureof a mucinoid cyst.



Bony enlargement of the DIP or PIP joints 1. Osteoarthritis X-ray series of the hand (optional)

Stiffness and decreased flexion or extension

Minimal signs of inflammation

Synovial thickening, swelling of the DIP, PIP, Inflammatory arthritis, Clinical diagnosis, erythrocyte sedimentation rate, x-ray series ofand MCP joints psoriatic (DIP joints) the hand, serology testing (optional)

rheumatoid arthritis

Stiffness and decreased flexion or extension

Loss of smooth motion of the PIP joint; 2. Trigger finger Local anesthetic block placed at the flexor tenosynovium triggering (optional)

Tenderness of the flexor tendons over the MCP joint in the palm

Pain reproduced by passive extension of the finger

Cystic swelling of the flexor tendons near Tenosynovial cyst Simple aspiration of the cystthe MCP joint

Normal range of motion of the finger

Thickening of the flexor tendons the palm Dupuytren’s contracture Examination

Loss of full extension of the fingers due to contracture

Tenderness of the MCP joint to palpation Monarticular Lidocaine injection of the jointposttraumatic arthritis of the MCP joint

MCP joint squeeze sign

Inability to fully extend the DIP joint and Mallet finger Clinical diagnosisthe characteristic flexion deformity

Pale gray, 3- to 5-mm cyst over the DIP Mucinoid cyst Clinical diagnosisor PIP joint

Associated osteoarthritic signs of the adjacent joint

HAND 133


COMMON HAND FRACTURES

FRACTURE OF THE PROXIMAL AND MIDDLEPHALANGES

SUMMARY: Fractures of the phalanges are classifiedby location, configuration (transverse or oblique),and effects of the fracture on the rotation and fore-shortening of the digit. The majority of these frac-tures can be managed nonsurgically.

IMMOBILIZATION: Extra-articular fractures that donot exhibit displacement, rotation, or angulationcan be treated with buddy taping and active rangeof motion exercises. Nearly all transverse fracturescan be managed in this fashion.

In addition, small chip fractures of the collateral liga-ments, dorsal chip fractures of the central slip of theextensor tendon at the base of the middle phalanx,and nondisplaced marginal fractures of the base ofthe proximal phalanx can be managed with buddytaping.

SURGICAL REFERRAL: Transverse fractures at thebase or neck of the proximal phalanx, nearly allspiral oblique fractures, and all comminuted andcondylar (intra-articular) fractures must be evaluatedby an orthopedic surgeon for possible open reduc-tion and internal fixation.

PROGNOSIS: All phalangeal fractures must be as-sessed for late complications, including malrotation,lateral deviation, recurvatum angulation, shorten-ing, intra-articular malunion, nonunion, tendon ad-herence, joint stiffness, and nail bed interposition.

FIGURE 7–25. Fracture of the proximal and middlephalanges.

HAND 135

ACUTE BOUTONNIÈRE INJURY Finger injuries lead-ing to an acute boutonnière deformity (tissue disruption ofthe central slip of the extensor tendon combined with tear-ing of the triangular ligament on the dorsum of the middlephalanx) can be treated by closed reduction as long as nobony chip fracture is present. The PIP joint is immobilizedin full extension with a PIP splint, and active and passiverange of motion exercises are performed daily. As with allfinger and thumb injuries, postimmobilization stiffnessmust be guarded against.

RUPTURE OF THE FLEXOR DIGITORUM PRO-FUNDUS TENDON This is an uncommon injurycaused by forced hyperextension of the DIP joint. Earlysurgery is the treatment of choice.

DISLOCATION OF THE PIP JOINT

SUMMARY: There are three types of dislocation ofthe PIP joint: dorsal, volar (rare), and rotatory (un-common). The dorsal or volar plate injury (with orwithout a small volar avulsion fracture) is the mostcommon type of dislocation and is the result of hy-perextension of the joint. Reduction is accomplishedby closed means.

IMMOBILIZATION: The PIP joint is immobilized witha PIP splint for 2 weeks (no more than 15 degreesof flexion) or with buddy taping for 3 to 6 weeks.Buddy taping has the advantage of allowing earlyactive motion (guarding against residual joint stiff-ness) while preventing hyperextension. Range ofmotion exercises are continued for several weeksafter immobilization.

SURGICAL REFERRAL: Surgical consultation is stronglyrecommended for dorsal dislocations associated withvolar lip fractures involving more than 20% of the ar-ticular surface and for nonreducible dislocations.

PROGNOSIS: Guarded. Full range of motion maynot be recovered, and late-onset osteoarthriticchanges can develop.

FIGURE 7–26. Dislocation of the PIP joint.


FRACTURE OF THE DISTAL PHALANX

SUMMARY: Fractures of the distal phalanx are clas-sified as longitudinal, transverse, or crushed-eggshell types. They account for 50% of all handfractures.

IMMOBILIZATION: Simple protective splinting for 3 to 4 weeks using a fingertip guard or Stack splint is combined with specific treatment of the soft tissueinjuries (e.g., laceration, subungual hematoma).The splint should not be placed close to the PIP jointso as to avoid joint stiffness.

SURGICAL REFERRAL: Fractures associated with softtissue injuries requiring debridement.

PROGNOSIS: Excellent.

FIGURE 7–27. Fracture of the distal phalanx.

• A comprehensive hand examination is the most impor-tant method of evaluating generalized hand arthralgia,especially if the patient is overly concerned about a fam-ily history of arthritis. Radiographic and serologic test-ing is nearly always normal unless the specific maneu-vers of the hand demonstrate objective findings of bonyenlargement, synovial thickening, or joint swelling.

• An efficient screening examination for classic rheuma-toid arthritis includes the following maneuvers: generalhand inspection, grip measurement, palpation of thePIP joints for tenderness, the MCP squeeze sign, exten-sion and flexion of the wrists, observation of gait andwalking on tiptoes, and the metatarsophalangealsqueeze. If the combination of these signs does notshow loss of range of motion or synovial thickening,rheumatoid arthritis is unlikely.

• The earliest sign of Dupuytren’s contracture is a trian-gular puckering of the dermal tissue over the flexor ten-don just proximal to the flexor crease of the finger. As

CLINICAL PEARLS

scarring progresses, nodules form, and the finger gradu-ally loses its flexibility.

• Patients of northern European descent are at the great-est risk for Dupuytren’s contracture. Less than 5% ofDupuytren’s contractures occur in patients with chronicliver disease.

• Tenosynovitis of the flexor tendons always precedes themechanical symptoms of triggering. However, not allpatients demonstrate active tenosynovitis at the timethey are examined. As the patient tries to avoid the trig-gering phenomenon (by using the finger less and less),the tenosynovial signs gradually subside, leaving thepatient with a painless mechanical triggering.

• Flexor tenosynovitis and mechanical triggering can beso dramatic as to preclude movement of the finger froma flexed position. This is called a fixed locked digit.

• Despite their size, tendon cysts rarely lead to mechani-cal dysfunction.

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CHAPTER 8: CHEST


Diagnoses

Rib cage (most common)CostochondritisSternochondritisTietze’s syndromeEpidemic pleurodyniaRib fracture, nondisplacedRib fracture, displaced

Sternum and sternoclavicular jointStrainInflammatory arthritis

Septic (intravenous drug abuse)

Referred pain to the chest wallHiatal hernia

CholelithiasisSplenic flexure syndromeCoronary artery disease

Aortic aneurysmPneumoniaPulmonary embolism

Confirmations

Local anesthetic blockLocal anesthetic blockExaminationExamination, local anesthetic blockChest compression sign, chest x-ray, or bone scanChest compression sign, chest x-ray

Local anesthetic blockLocal anesthetic block, abnormal erythrocyte sedi-

mentation rate, exam correlationsAspiration and culture

Gastrointestinal cocktail taken orally, barium swal-low, endoscopy

Liver chemistries, ultrasoundExamination, abdominal x-rayElectrocardiogram, creatine phosphokinase, tro-

ponin, or angiogramComputed tomography of the chest, angiogramChest x-ray, complete blood cell count, culturesO2 saturation, d-dimer, lung scan, computed tomog-

raphy scan, angiogram


INTRODUCTION The initial evaluation of the patientwho complains of anterior or anterolateral chest pain mustinclude a thorough examination of the chest for evidence ofcoronary, pulmonary, pleural, major vascular, or upper ab-dominal disorders. At times, this entails full physical, radio-graphic, and electrophysiologic evaluation in the patientwith significant risk factors for major heart, lung, vascular,or abdominal disease, despite a strong suspicion of chestwall abnormality. By contrast, if the patient is young andhas a low risk of major chest disorders, and symptoms aredescribed as superficial, localized, and aggravated by directchest wall pressure or chest movement in general, a localmusculoskeletal process should be considered and unequiv-ocally suggested to the patient to avoid unnecessary anxiety.

Of the various structures of the chest wall, the ribs andcostal cartilages are the most susceptible to injury and inflammation. Rib contusions and nondisplaced rib frac-tures commonly occur after mild chest wall trauma. Costo-chondritis and its analogous condition, sternochondritis, in-volve local irritation and inflammation of the junctions ofthe cartilaginous portions of the thorax cage with the ribsand sternum, respectively. Although the condition can re-sult from minor trauma or follow open heart surgery, themajority of cases are idiopathic.

Major trauma to the chest from falls, motor vehicle acci-dents, and blunt trauma is more likely to cause displacedrib fractures. Patients with multiple displaced fracturesmust be observed closely for possible hemothorax or pneu-mothorax. In addition, severe decelerating injuries to theupper chest can cause fractures of the sternum or proximalclavicle or fracture or dislocation of the sternoclavicularjoint. The amount of blunt trauma or force associated withthese fractures is so great that life-threatening associated in-juries to underlying great vessels and lung parenchymashould be sought.

Epidemic pleurodynia is an irritation and resulting spasmof the intercostal muscles, commonly known as the devil’sgrip. This is a rare condition thought to be of viral origin,occurring in sporadic outbreaks.

Xiphodynia is a rare but unique cause of anterior chestpain. Irritation and inflammation of the junction between thesternum and the xiphoid process cause a localized pain andtenderness and an unusual sensitivity. Pressure placed directlyover the xiphoid can incite an autonomic reaction consistingof nausea, vomiting, abdominal pain, and sweating.

SYMPTOMS Chest pain can arise from the chest wall orinternal organs. In general, musculoskeletal chest pain ischaracterized by superficial, focal tenderness and is aggra-vated by chest wall movement (lying on the side, chest ex-pansion with a deep breath, or reaching overhead with out-stretched arms). Chest pain arising from the heart, lungs,pleura, major vessels, or upper abdomen is more often ac-companied by additional symptoms, such as palpitations,shortness of breath, pleuritic pain, or nausea and vomiting.

Any of the structures that make up the chest wall can causechest pain, including the ribs, costal cartilage, costochondraljunctions, intercostal muscles, sternum, xiphoid process, andsternoclavicular joints. The chest pain arising from these struc-tures typically is described as a focal irritation unless more

than one rib or costochondral junction is involved. Rib con-tusions and fractures are tender directly over the affectedbone. Patients with costochondritis describe discrete tender-ness at the junction of the rib and costal cartilage in a line ex-tending from the sternoclavicular joint through the nipples.Patients with sternochondritis experience focal tenderness ap-proximately 1 inch from the midline directly over the junctionof the sternum and the costal cartilage. Xiphodynia, or in-flammation between the lower sternum and the xiphoidprocess, is characteristically tender over a dime-sized area atthe very end of the sternum.

Contrast these with epidemic pleurodynia. Inflammationof the intercostal muscles causes a linear type of pain fol-lowing the course of the intercostal muscle between two ad-jacent ribs. The pain is intermittent and cramplike at inter-vals of 15 to 20 minutes.

Pain arising from the sternum tends to be more persis-tent, especially when caused by infection. As with otherstructures of the chest wall, the pain is aggravated by deepbreath, coughing, and direct pressure.

Pain arising from the sternoclavicular joint is always focal.However, unlike pain in other structures of the chest wall, itis not consistently aggravated by chest wall expansion or com-pression. Movement of the arms is much more aggravating.

Any of these conditions, with the exception of the stern-oclavicular joint disorders and xiphodynia, can lead tosplinting of respiration and a sense of shortness of breathwhen the pain is severe. True oxygen deprivation and desat-uration are not typical and suggest primary involvement ofthe lungs or heart.

EXAMINATION General observations are made of themovement of the upper torso and the patient’s posture.The patient’s breathing pattern and the general movementof the bony thorax are used to assess the restrictive condi-tions affecting the chest wall (e.g., scoliosis, rib trauma).These observations are combined with an assessment of thepatient’s vital signs and degree of oxygenation. If the pulseis irregular or more than 110 beats per minute or the respi-ratory rate is more than 20 per minute with signs of laboredbreathing or poor color, further evaluation of the patient’soxygenation and vital organ function is mandatory. If thevital signs, coloration, and level of distress are unremark-able, then the physician proceeds with an examination ofthe chest wall and associated musculoskeletal structures.

Rib fracture, rib contusion, and costochondritis are as-sessed by direct palpation of the affected areas and by thechest compression maneuver. Palpable tenderness andswelling of the chondral junctions is highly suggestive ofcostochondritis and sternochondritis.

Focal tenderness over the lowest part of the sternum sug-gests xiphodynia. Tenderness and swelling directly over thesternoclavicular joint with or without pseudoenlargement ofthe clavicle are characteristic of arthritis of the articulationbetween the upper sternum and the proximal end of theclavicle.

Pain along the course of an intercostal muscle suggests en-demic pleurodynia, shingles, or radiculopathy from a thoracicvertebral lesion. Epidemic pleurodynia is characterized by lo-cal muscular tenderness. Shingles and thoracic radiculopathy

CHEST 139

lack focal tenderness. However, the skin corresponding to the thoracic dermatotome is hypesthetic or exhibits somedegree of heightened sensation caused by nerve irritation. Inthe case of shingles, tenderness occurs when the rash appears.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL CHEST WALL FUNCTION

The next six maneuvers represent the minimal examinationof the patient presenting with chest symptoms. Range ofmotion measurement and screening maneuvers for epi-condylitis and olecranon bursitis provide enough informa-tion to triage to x-ray, order appropriate lab, to suggest gen-eral treatment recommendations, or proceed to moredetailed examination and treatment.

1. Observe the general movement of the chest.a. Observe the movement of breathing.b. Measure chest expansion.

2. If the patient is short of breath, is coughing, has pal-pitations, or is nauseated, then perform a thoroughexamination of the chest for evidence of coronary,pulmonary, pleural, major vascular, or upper ab-dominal disorders.

3. Palpate the integrity of the bony thorax (ribs andsternum).

4. Assess the degree of chest wall inflammation, espe-cially the junctions of the costal cartilages.

ESSENTIAL EXAMINATION OF THE CHEST WALL

BOX 8-1

GENERAL UPPER BODY MOVEMENT AND BREATHING PATTERN

SUMMARY: Difficulties in moving in the exam room,performing simple tasks such as removing a T-shirt,or changing position on the exam table can be thefirst clue to the diagnosis of a chest wall condition.

MANEUVER: Without prompting the patient, the examiner observes the patient’s general movement,noting the ease of movement and the consistency of arm and torso motions.

INTERPRETATION: Cautious movement, general stiff-ness, and restricted movement of the chest are char-acteristic of conditions affecting the bony thorax.Inconsistencies between the examiner’s first obser-vations of posture, general movement, and functionand the patient’s behavior during examination canindicate malingering.

FIGURE 8–1. Observe the patient’s general upper bodymovement and breathing pattern.

BREATHING PATTERN

SUMMARY: The bony thorax consists of the sternum,the costal cartilages, the ribs, and the vertebralbodies. Chest wall splinting is a nonspecific symp-tom but is typical in patients with true chest walldisorders.

MANEUVER: Observations with and without distrac-tion are made of the patient’s ability to move aboutthe exam room, ability to adjust the examinationgown, and breathing pattern.

INTERPRETATION: Shallow breathing or splinting in-dicates chest wall injury, most commonly to thebony ribs, but is also characteristic of pleurisy,pneumonia, and inflammatory pleural effusion.

FIGURE 8–2. Breathing pattern, splinting with injury to thethorax.



SUMMARY: The chest wall consists of the sternum,the costal cartilages, the ribs, and the vertebralbodies. Anteroposterior compression of the chest isthe optimal screening to assess the integrity of thebony thorax.


INTERPRETATION: A positive chest compression testis seen with any significant injury to the thorax, in-cluding rib contusions, rib fracture, nondisplacedrib fracture, costochondritis, and sternal fracture.FIGURE 8–3. Chest compression test to assess the integrity

of the chest wall.

PALPATION

SUMMARY: Irritation and inflammation of the junctions between the costal cartilage and the adjacent rib and sternum is called costochondritisand sternochondritis, respectively. Most cases are idiopathic.

MANEUVER: The intercostal spaces are palpatedand marked with a pen. The rib is located halfwaybetween the two spaces. Sternochondral tendernessis located 1 inch from the midline. Costochondraltenderness is located along the line between thesternoclavicular joint and the center of the nipple.

INTERPRETATION: Most patients with costochondritisor sternochondritis have one irritated and inflamedjunction. When multiple junctions are tender, thecentralmost junction usually is responsible for thepatient’s symptoms.

FIGURE 8–4. Palpation of the costochondral and sternochon-dral junctions.

CHEST 141

CHEST WALL EXPANSION

SUMMARY: Chest wall expansion measurements are the most objective means of assessing impairedchest wall movement. Originally, this measurementwas used suggested as an objective means of as-sessing the stiffness associated with ankylosingspondylitis. From a practical point of view, thismeasurement can be used to define the severity of the condition in question and assess the successof treatment.

MANEUVER: The measuring tape is placed at thelevel of T6 and the lower sternum. The patient isasked to fully exhale, and the examiner records the circumference of the chest. The patient is thenasked to inhale fully and then hold the breath in.The chest expansion is measured once again, andthe difference in the two measurements is recorded.

INTERPRETATION: The normal chest expansion is upto 21⁄2 inches.

FIGURE 8–5. Use a tape measure to assess the patient’s chestwall expansion.

PALPATION

SUMMARY: Epidemic pleurodynia, shingles, andthoracic radiculopathy cause pain that wrapsaround the chest wall, following the course of an intercostal space.

MANEUVER: The intercostal spaces are palpatedand marked with a pen. The intercostal muscle ispalpated for local tenderness and spasm. Lighttouch and pain sensation are tested along thecourse of the intercostal space.

INTERPRETATION: Tenderness over the muscle suggests epidemic pleurodynia. Hypersensitivity orloss of sensation is seen with shingles and vertebralbody lesions at thoracic levels T7–T1. Shingles ischaracterized by a grouping of erythematous vesic-ular lesions along the course of the intercostalspace.

FIGURE 8–6. Palpation of the intercostal muscles to assess epi-demic pleurodynia.



TRIAGE TO X-RAY For patients with a history of blunttrauma to the chest, those with osteoporosis, acute chestpain, and severe paroxysms of cough, or those with chestpain and associated symptoms including palpitations, dizzi-ness, productive cough, pleurisy, nausea, and vomiting:

• Order a chest x-ray and cardiogram if breathing is im-paired (pneumonia, pulmonary embolus, angina, coro-nary artery disease).

• Order a chest x-ray and tangential views of the ribs if thepatient has sustained a blow to the chest wall (rib contu-sion, rib fracture).

• Order a chest x-ray and tangential views of the ribs if thepatient has osteoporosis and has acute pain in the chest af-ter paroxysms of coughing (rib contusion, rib fracture).

• Order chest x-ray and special views of the sternum if thepatient has persistent pain over the sternum (fracture, os-teomyelitis after open heart surgery).

• Order a chest x-ray and thoracic spine films if the patientdescribes pain wrapping around the chest wall (compres-sion fracture, metastatic disease, epidural abscess, primarydisease of the spinal cord).

TRIAGE TO THE LAB For patients with chest pain,cough, fever, and significant respiratory insufficiency:

• Order a chest x-ray, complete blood cell count, erythro-cyte sedimentation rate, and blood cultures for patientswith acute chest pain, cough, fever, and an acute changein respiratory function (e.g., pneumonia, pulmonary em-bolus, pleural effusion, pneumothorax).

CONSIDER A BONE SCAN For patients with focalchest wall pain and a history of malignancy, with persistentrib pain, or with radicular pain wrapping around the chestwall (compression fracture, miscellaneous fractures of thespine, osteomyelitis, rib contusion or fracture, and metasta-tic disease).

CONSIDER MRI For patients with radicular pain wrap-ping around the chest wall (compression fracture, miscella-neous fractures of the spine, osteomyelitis, and metastaticdisease).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate chest wall pain and stiffness,unrestricted movement, and normal breathing:

• Avoid vigorous exercise, lifting, twisting, pushing, andpulling.

• Avoid lying on either side.• Apply ice to the tender areas of the chest wall.• Use a nonsteroidal anti-inflammatory medication for 10

to 14 days with a taper over 7 days at the end.• Recommend an Ace wrap, wide bra, or a rib binder,

but only if there are no risks of pulmonary complications(optional).

DETAILED EXAMINATION: SPECIFIC CHEST WALLDIAGNOSES

Perform a detailed examination of the chest if the patient haspersistent or chronic symptoms, moderate to severe chest wallpain, severe bony tenderness, significant breathing impair-ment, intense paraspinal muscle spasm, or radiculopathy.

CHEST 143


SUMMARY: Enter atop the center of the rib; angle the syringe perpendicular to the skin. The injections should be placed flush against the carti-lage adjacent to the costochondral junction usingmild pressure.


DEPTH: 1⁄2 to 1 inch, depending on the location onthe chest.

VOLUME: 1 to 2 mL local anesthetic, 1⁄2 mL D80 orK40, or both.

FIGURE 8–8. Local anesthetic block to confirm costochondri-tis or sternochondritis.

PALPATION

SUMMARY: Inflammation of the junctions of thecostal cartilage and the ribs and sternum is calledcostochondritis and sternochondritis, respectively.When the inflammatory reaction is complicated bya unique bulbous enlargement of the joint, the con-dition is called Tietze’s syndrome.

MANEUVER: The intercostal spaces are palpatedand marked with a pen. The center of the rib is located halfway between the two spaces.Sternochondral tenderness is located at the junctionof the cartilage and the sternum, approximately 1 inch from the midline. Costochondral tendernessis located at the junction of the cartilage and therib that follows a line extending from the sternoclav-icular joint through the center of the nipple.

INTERPRETATION: Most patients with costochondritisor sternochondritis have one irritated and inflamedjunction. When multiple junctions are tender, thecentralmost junction usually is responsible for the symptoms.

FIGURE 8–7. Palpation of the local tenderness of costochondri-tis and sternochondritis.

COSTOCHONDRITIS Inflammation between the costal carti-lage and the end of the rib is called costochondritis. Inflammationbetween the costal cartilage and the bony sternum is called ster-nochondritis. Inflammation and bulbous enlargement of the costo-chondral junction is called Tietze’s syndrome.


NONDISPLACED RIB FRACTURE Simple nondisplaced ribfractures (cracks) result from a minor blow to the chest or a fallonto the bony thorax. Focal tenderness, a positive chest compres-

sion sign, and relief with local anesthesia are useful in making a presumptive diagnosis. Chest radiographs are normal in most cases.

PALPATION

SUMMARY: The anterolateral and posterolateral ribsare the areas of the chest wall that are most vulner-able to injury. Ribs 6 through 10 are most oftenfractured.

MANEUVER: The patient is placed in the lateral de-cubitus position. The center of the ribs are palpatedand marked with a pen. The length of the rib is pal-pated for local tenderness and deformity.

ADDITIONAL SIGNS: The rib compression sign ispositive. Palpable deformity suggests a displacedfracture. Signs of pneumothorax may be present. If pneumothorax has occurred, subcutaneous em-physema may be present.

INTERPRETATION: Patients with bruised ribs havetenderness without deformity. Patients with dis-placed fractures have tenderness and deformity.

FIGURE 8–9. Palpation of the rib.


SUMMARY: The intercostal nerve and vascular bundle are located on the undersurface of the rib.Local anesthetic block is placed between the areaof injury and the vertebral column. Before placingthe anesthetic at the undersurface of the rib, the ex-aminer determines the depth of injection by insert-ing the needle directly over the center of the rib.


DEPTH: 1⁄2 to 1 inch, depending on the location onthe chest wall.

VOLUME: 1 to 2 mL local anesthetic, 1⁄2 mL D80, or both.

NOTE: Never advance the needle more than 1⁄2 inchfurther than the depth of the rib.

FIGURE 8–10. Local anesthetic block to confirm costochon-dritis or sternochondritis.

CHEST 145

PALPATION

SUMMARY: The sternoclavicular joint is formed bythe upper portion of the sternum and the proximalclavicle. When the joint swells, the proximal clavicleprojects anteriorly. The anterior position of the clavi-cle causes a pseudoenlargement of the clavicle.

MANEUVER: The sternal notch, proximal clavicle,and center of sternum are palpated and markedwith a pen. The sternoclavicular joint is palpated at the junction of the sternum and the proximal clav-icle, approximately 3⁄4 to 1 inch from the midline.

ADDITIONAL SIGNS: Swelling in the sternoclavicu-lar joint gives the false impression of an enlargedclavicle, the pseudoenlargement of the clavicle. Thepatient’s pain can be reproduced by passive ad-duction of the shoulder across the chest.

INTERPRETATION: Sternoclavicular joint involvementis uncommon. Sternoclavicular joint strain is charac-terized solely by local tenderness. Sternoclavicularjoint local tenderness and pseudoenlargement ofthe clavicle are seen with sternoclavicular jointarthritis, most commonly Reiter’s disease. A red,hot, swollen joint is a unique complication of intra-venous drug abuse (septic arthritis usually is due toStaphylococcus aureus or Gram-negative bacilli).

FIGURE 8–11. Palpation of the sternoclavicular joint.

mal end of the clavicle. The prominence of the clavicle, often mis-takenly diagnosed as a bony tumor, is due to joint swelling anddisplacement, which create the appearance of an enlarged clavicle.

STERNOCLAVICULAR JOINT ARTHRITIS Sternoclavicularjoint strain from seat belt injuries or falls to an outstretched armand its long-term sequela, sternoclavicular joint arthritis, are char-acterized by local tenderness and pseudoenlargement of the proxi-


SUMMARY: Enter atop the center of the proximalclavicle with the needle perpendicular to the skin.The injection should be placed flush against theproximal end of the clavicle, just adjacent to thecenter of the joint, using mild pressure.



VOLUME: 1 mL local anesthetic, 1⁄2 mL K40, or both.

FIGURE 8–12. Local anesthetic block to identify the stern-oclavicular joint as the source of the patient’s pain.


EPIDEMIC PLEURODYNIA Epidemic pleurodynia, or thedevil’s grip, is an acute inflammation of the muscles of the chestwall. The presumptive diagnosis is suggested by focal pain, muscle

tenderness, and chest wall irritation between two adjacent ribs.The diagnosis can be confirmed by placing local anesthetic directlyinto the affected intercostal muscle.

PALPATION

SUMMARY: Epidemic pleurodynia is characterizedby dramatic local tenderness and spasm of the in-tercostal muscles. Often one intercostal space is af-fected more than another, although the patient maydescribe a wide area of discomfort.

MANEUVER: The intercostal spaces are palpatedand marked with a pen. The intercostal muscle ispalpated for local tenderness and spasm.

ADDITIONAL SIGNS: The chest compression sign is negative. The sensory testing of the intercostalspace should be normal. The overlying skin is freeof rash.

INTERPRETATION: Tenderness over the muscle sug-gests epidemic pleurodynia. Hypersensitivity or lossof sensation is seen with shingles and vertebralbody lesions at thoracic levels T7–T1. Shingles ischaracterized by a grouping of erythematous vesic-ular lesions along the course of the intercostalspace.FIGURE 8–13. Palpation of the intercostal space.


SUMMARY: The intercostal muscle is located at thesame depth as the adjacent ribs. Local anestheticblock is placed in the most proximal portion of the irritated area, closest to the vertebral column.Before placing anesthetic at the undersurface the ofthe rib, the examiner determines the depth of injec-tion by inserting the needle directly over the centerof the rib.


DEPTH: 1⁄2 to 1 inch, depending on the location onthe chest wall.


NOTE: Never advance the needle more than 1⁄2 inchfurther than the depth of the rib.

FIGURE 8–14. Local anesthetic block to confirm involvementof the intercostal muscle.

CHEST 147

XIPHODYNIA Xiphodynia is a rare cause of chest pain. Focalinflammation and pain are located at the junction of the xiphoidand lower sternum. Direct pressure causes pain and a visceral re-sponse (nausea and abdominal discomfort).

PALPATION

SUMMARY: The xiphoid process is an inch-longbone attached to the inferior aspect of the sternum.Injury and inflammation occur at the junction ofthese two bones.

MANEUVER: The inferior aspect of the sternum isidentified and marked. The xiphoid process extendsapproximately 1 inch inferior to the sternum in themidline between the medial aspects of the ribs. The maximum tenderness is located at the junctionof the sternum and xiphoid process.

ADDITIONAL SIGNS: Firm pressure over the xiphoidcauses tenderness and an autonomic response consisting of nausea, abdominal discomfort, andsweating.

INTERPRETATION: Local tenderness in the midline directly over the xiphoid process unequivocally defines xiphodynia. The local tenderness of sternalinjury, fracture, or osteomyelitis typically is morediffuse and extends over a large area of the bone.The local tenderness of sternochondritis is alwaysoff the midline.

FIGURE 8–15. Palpation of the xiphoid process.


SUMMARY: Enter directly over the junction of the sternum and the xiphoid process in the midline.Maintain the angle of the syringe perpendicular tothe skin. The injection should be placed flush againstthe firm to hard bone adjacent to the junction, on thesternal or xiphoid side of the articulation.


DEPTH: 1⁄2 to 1 inch, depending on the location onthe chest.


FIGURE 8–16. Local anesthetic block to confirm xiphodynia.


EXAMINATION MANEUVERS DIAGNOSIS CONFIRMATION PROCEDURES

Focal tenderness over the cartilage Costochondritis Local anesthetic block at the junction of the cartilage with the or sternochondritis rib or sternum, respectively

+ Chest wall compression sign

Diminished chest expansion

Focal tenderness over the rib after injury #1: Rib fracture Rib x-raysor contusion

+ Chest wall compression sign Local anesthetic block over the rib

Diminished chest expansion (pain)

Enlargement and focal tenderness Sternoclavicular joint Apical lordotic views of the chestof the sternoclavicular joint injury or arthritis

Pain aggravated by passive adduction of the shoulder MRI of the upper chest

Focal tenderness and spasm Epidemic pleurodynia Chest x-rayof an intercostal muscle

+ Chest wall compression sign Local anesthetic block in the intercostal muscle

Diminished chest expansion (pain)

Focal tenderness over the xiphoid Xiphodynia Local anesthetic block over the junction of the sternum and the xiphoid

Focal tenderness over the sternum Sternal injury or infection Sternum x-rays

+ Chest wall compression sign Abnormal bone scan

Diminished chest expansion


• Patients with inflammation of the chest wall (costo-chondritis or sternochondritis) often present with ten-derness over more than one rib. In most cases the ribthat manifests the greatest sensitivity to palpation is thefocus of the patient’s pain. The sensitivity of the ad-joining ribs often is referred pain. Local anestheticplaced at the most involved rib often is sufficient tocontrol the chest wall inflammation.

• Swelling of the sternoclavicular joint causes subluxationof the clavicle, leading to what appears to be an en-largement of the bone, or pseudoenlargement of theclavicle.

CLINICAL PEARLS

• Epidemic pleurodynia often is misdiagnosed as rib contu-sion. The classic signs of rib contusion and rib fracture—chest wall compression and direct rib palpation—are notseen with pleurodynia. Pleurodynia is characterized byintercostal muscle tenderness and spasm located be-tween the ribs.

• Sternal infection is rare outside the setting of open heartsurgery.

• Chest wall compression should be performed in severaldifferent directions to rule out rib fracture.

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CHAPTER 9: LUMBOSACRAL SPINE


Diagnoses

Lumbosacral back strain (most common)Unaccustomed or improper use

Reactive lumbosacral back strainOsteoarthritisScoliosisSpondylolisthesisHerniated disk

Compression fracture

Epidural process

Lumbosacral radiculopathy (sciatica)Herniated diskOsteoarthritis (spinal stenosis)Intra-abdominal processWallet sciaticaCauda equina syndrome

Sacroiliac joint strainSacroiliitis

Coccydynia

Referred painKidney (e.g., pyelonephritis, stones)AortaColon (e.g., appendicitis, cecal carcinoma,

rectal carcinoma)Pelvis (e.g., tumor, pregnancy)

Confirmations

Examination: local tenderness, Schober measurement

X-ray: routine back seriesX-ray: standing scoliosis viewsX-ray: routine back series and the oblique viewsComputed tomography (CT) scan or magnetic

resonance imaging (MRI)

X-ray: lateral view of the back, bone scan, MRI

MRI

CT scan or MRICT scan or MRIUltrasound or CT scanHistoryMRI

Local anesthetic blockX-ray: standing anteroposterior pelvis; the oblique

views of the sacroiliac joints; bone scan


Urinalysis, intravenous pyelogram, ultrasoundUltrasound, CT scanningHemoccult, barium enema, sigmoidoscopy,

colonoscopyExamination, ultrasound

INTRODUCTION The back is the most complicated andmisunderstood area of the skeleton. With a variety of con-ditions, a systematic approach to the differential diagnosisof low back pain involves separation of these conditionsinto five general categories: structural, radiculopathic,sacroiliac, traumatic, and medical.

Structural causes of low back pain dominate the differen-tial diagnosis and include irritation or injury to the sup-porting paraspinal muscles, the complex network of sup-porting ligaments, facet joint cartilage, and the vertebralbones. Of the various structural elements of the spinal col-umn, the paraspinal muscles are most susceptible; therefore,low back strain is the most common cause of structuralback pain. Reversible strain of the paraspinal muscles resultsfrom overuse of improperly stretched and toned muscles.However, recurrent or chronic muscle strain and spasm canresult from any condition that threatens the structural in-tegrity of the lower back (abnormal alignment from scolio-sis, kyphosis, and spondylolisthesis, chronic inflammationfrom spondylitis, wear of the facet joint cartilage and diskfrom degenerative arthritis, or loss of normal alignmentfrom compression fracture). As with the cervical spine, theirritation and spasm of the paraspinal muscles are the body’sprotective reflex whenever the spinal column, spinal cord,or spinal nerve is in jeopardy.

Lumbar radiculopathy is the next most common prob-lem affecting the lower back. Compression of the spinalnerves, spinal roots, or spinal cord causes localized low backstrain (reflexive paraspinal muscle spasm to protect thespinal elements) or radicular symptoms in the lower ex-tremities (sciatic pain and numbness). Degenerative disk dis-ease, herniated nucleus pulposus (HNP), and degenerativearthritic narrowing of the lateral recesses are the primarycauses. Spinal stenosis (the most extreme case of degenera-tive changes), epidural abscess, epidural metastatic disease,and primary involvement of the spinal cord are less com-mon causes. Lumbar radiculopathy is graded according tothe degree of nerve compression. Progressive pressure causessensory symptoms first, followed by sensorimotor and sen-sorimotorvisceral (cauda equina syndrome) symptoms.

The sacroiliac joint is a unique cause of low back pain.Most patients describe a well-localized area of irritation overthe sacral area, although some patients describe low backpain similar to that due to the structural causes of pain, es-pecially when the paraspinal muscles react dramatically.Injury and strain to the supporting iliolumbar and iliosacralligaments (sacroiliac strain) and inflammation of the joint(sacroiliitis) in the setting of active spondyloarthropathyare the two most common causes.

Nearly all traumatic injuries to the spine demand the at-tention of the orthopedic or neurosurgical specialists withthe exception of the less severe compression fractures. It isnot uncommon for an osteoporotic patient to present to theprimary care provider with a cough or minor injury inducedby partial collapse of a vertebral body.

Finally, if the four intrinsic causes of low back pain arenot identified, a thorough search for a medical cause of

referred pain must be sought. Common causes includepyelonephritis, nephrolithiasis, gynecological disorders, as-cending and descending lesions of the colon, and athero-sclerotic involvement of the abdominal aorta. Associatedsymptoms of dysuria, hematuria, menometrorrhagia, bowelirregularity, and claudication are clues to the presence of amedical cause of back pain.

SYMPTOMS Conditions directly affecting the backcause lower back pain, muscle spasms, stiffness and im-paired movement, radicular symptoms, or a combination ofthese symptoms.

Diffuse low back pain is one of the most common symp-toms because of the universal occurrence of lumbosacralstrain (acute irritation and spasm of the paraspinal muscles).Although the pain can be poorly localized, vague in de-scription, and variable in intensity, the diagnosis of lum-bosacral strain is strongly suggested by aggravation causedby specific movements of the back. Most episodes of acuteback strain result from poor posture, improper lifting, or un-accustomed use of these supporting muscles. However, it isalso the body’s final common pathway for any process thatthreatens the integrity of the structure of the spinal column,spinal nerves, or spinal cord. Unexplained lumbosacralstrain (i.e., unassociated with an obvious physical event),should alert the clinician to an underlying structural abnor-mality, radiculopathy, or sacroiliac joint disorder.

Focal low back pain is encountered much less com-monly. Pain along either side of the spine is most oftencaused by paraspinal muscle spasm that accompanies scol-iosis, osteoarthritis, or sacroiliac strain. On the other hand,pain localized to the center of the spine suggests involve-ment of the vertebral column (fracture, tumor, infection, orherniated disk). In either case, if the process is severe, radic-ular pain may accompany the clinical presentation.

Low back pain accompanied by pain or paresthesia re-ferred down the leg (sciatica) is the classic presentation oflumbar radiculopathy. The severity of these symptomsvaries from patient to patient and depends on the underly-ing cause, the acuteness of the process, the degree of nervecompression, and the degree of reactive paraspinal musclespasm. These factors tend to be quite dynamic, changingover time, interacting, and compounding one another. Forexample, sensory radiculopathy (impairment limited to thesensory branches of the spinal nerve) can progress to senso-rimotor radiculopathy (impairment of both sensory andmotor nerves) as the reactive paraspinal muscle spasm placesgreater localized pressure on the spine.

Focal low back pain localized below the iliac crest is theclassic location of sacroiliac joint irritation or inflammation.

Focal low back pain localized in the midline of thegluteal crease is classic for coccydynia.

Low back pain that is unassociated with focal back tenderness, a change in mobility, stiffness, or radicularsymptoms suggests referred pain from the abdomen.Pyelonephritis and renal colic are the most common med-


ical causes of back pain. However, any retroperitonealprocess (e.g., retrocecal appendix, cecal carcinoma, pelvictumor, abdominal aneurysm) can mimic the pain of lowback strain.

EXAMINATION Conditions affecting the lumbosacralspine are exceedingly common and can range from the in-convenience of a minor back strain to the severe incapacita-tion of a compression fracture or spinal stenosis. The exam-ination of the back should always begin with assessment ofthe patient’s overall function. This is accomplished by ob-serving the patient’s posture and gait, the ability to climbonto the exam table, and the ease or difficulty in recliningand sitting up.

Next, the examiner assesses the integrity of the spinal col-umn by inspecting the lumbosacral curve, palpating thespinous processes, and palpating and percussing each indi-vidual vertebra. Palpation of the paraspinal muscle groupsand measurement of lumbar flexion using the Schober testare used to assess the degree of reactive muscle strain andoverall spinal mobility. The straight leg raise maneuver anda detailed neurologic exam of the lower extremities are usedto determine the degree of lumbar radiculopathy.

Irritation and inflammation of the sacroiliac joint are as-sessed by direct palpation of the joint and by Patrick ma-neuver (recreating the patient’s pain by applying torque tothe sacroiliac joint; forced abduction and external rotationof the hip).

Finally, the abdomen and pelvis are examined when theexamination of the back does not demonstrate localized ten-derness, impaired mobility, or evidence of radiculopathy.

ONE-MINUTE SCREENING BACK EXAM:MANEUVERS ASSESSING OVERALL BACKFUNCTION

The next six maneuvers represent the minimal examinationof the patient presenting with back symptoms. Observationof general function, range of motion measurement, andscreening maneuvers for lumbosacral strain, radiculopathy,and sacroiliac strain provide enough information to triageto x-ray, order appropriate labs, suggest general treatmentrecommendations, or proceed to more detailed examinationand treatment.

LUMBOSACRAL SPINE 151

Structural back disease Low back strainScoliosisSpondylolisthesisOsteoarthritis of the backCompression fracture

Radiculopathy Herniated diskSpinal stenosisCauda equina syndromeEpidural abscessEpidural metastasisCompression fracture

Sacroiliac joint Sacroiliac strainSacroiliitis

Coccyx CoccydyniaReferred pain Nephrolithiasis,

pyelonephritisAortic aneurysmDisease of the colonPelvic tumor, pregnancy

DIFFERENTIAL DIAGNOSIS OF BACK PAINBASED ON ANATOMIC AREA

BOX 9-1

1. Observe the patient’s general movement, includinggait, difficulties in changing positions, and posture.

2. Palpate the paraspinal muscles and perform aSchober test.

3. Define the degree of radicular pain and perform astraight leg raise maneuver.

4. Palpate and percuss each of the five spinousprocesses.

5. Palpate the sacroiliac joint and perform a Patrick maneuver.

6. Palpate the sacrococcygeal junction.7. Examine the abdomen for a medical cause of low

back pain.

ESSENTIAL EXAMINATION OF THE LUMBOSACRAL SPINE

BOX 9-2


GAIT

SUMMARY: Walking with upright posture requiresan intact lumbosacral spine, spinal nerves, andspinal cord as well as flexible and strong lower extremity muscles.

MANEUVER: The patient is asked to walk throughthe exam room while the examiner observesheel–toe walking and general coordination, watching for antalgic gait and spasticity.

INTERPRETATION: Full upright posture will be affected by an abnormal alignment of the spine(scoliosis), osteoarthritis of the spine (spinal steno-sis), paraspinal muscle spasm (lumbosacral strain),and disorders of the spinal nerves and spinal cord(lumbar radiculopathy). Observation of the patient’sgait is useful in determining the severity of the underlying process.

FIGURE 9–1. Observe the patient’s gait.

SCHOBER TEST

SUMMARY: Bending forward at the waist combinesthe movement of the facet joints, the lumbosacralligaments, and the paraspinal muscles of the lum-bosacral spine; movement of the sacroiliac joint;and flexion of the hips. The Schober test objectivelymeasures the contribution of the lumbosacral backto flexion. The Schober measurement is considerednormal if the distance between the marks increasesby 50% (from 10 to 15 cm), the marks graduallyand smoothly move apart, and the maneuver doesnot incite back pain.

MANEUVER: The maneuver begins with the patientstanding. Two marks are made over the spine, oneat the level of the iliac crests and one at 10 cm.Then the patient is asked to bend forward slowlyand to report when symptoms are felt. The tape isheld at the upper mark. As the patient activelybends, the point at which pain occurs and the pointof maximum flexion are measured.

INTERPRETATION: The Schober test provides a roughgauge of the severity of the underlying condition af-fecting the lumbosacral spine. Its most practical useis to rule out significant structural and spinal disor-ders. A 50% increase in the measurement effectivelyexcludes significant back disease and is consistentwith sacroiliac strain, medical causes of back pain,or drug-seeking patients feigning back pain.

FIGURE 9–2. Perform a objective measurement of back flexionusing the Schober test.


PARASPINAL MUSCLES

SUMMARY: The erector spinae muscles (theparaspinal muscles) arise from the thoracolumbarfascia, attach to each spinal level, and extend upthe spine to the base of the skull.

MANEUVER: The patient is asked to sit up asstraight as is comfortable with attention to posture.Local tenderness and muscle spasm are comparedside to side. The optimal site of palpation is ap-proximately 2 inches from the midline. The irritabil-ity and spasm can be enhanced by asking the pa-tient to rotate to the right and then to the left at thewaist.

INTERPRETATION: Paraspinal muscle spasm can be unilateral with common back strain, scoliosis,disk herniation, or an epidural process. Bilateralparaspinal spasm is more common and can occurwith any underlying back process.

FIGURE 9–3. Palpate the paraspinal muscles to assess irri-tability and spasm.

SPINOUS PROCESSES OF THE VERTEBRALBODIES

SUMMARY: The spinous process, the most accessi-ble portion of the vertebra to palpation, connects tothe vertebral body through the posterior elements ofthe neural arch.

MANEUVER: The patient is asked to sit up asstraight as is comfortable with attention to posture.The individual spinous processes are palpated withfirm pressure. If simple palpation does not recreatethe patient’s pain, then percussion of each individ-ual spinous process is performed. Percussion canbe accomplished using a reflex hammer or the ul-nar side of the fist.

INTERPRETATION: Focal tenderness implies a moreinvolved process such as acute disk herniation,compression fracture, or epidural process.

FIGURE 9–4. Palpate and percuss the spinous processes ofthe vertebral bodies.


STRAIGHT LEG RAISE MANEUVER

SUMMARY: The straight leg raise maneuver is themost important screening maneuver for acuteradiculopathy. It is much less sensitive when the patient has chronic nerve irritation (e.g., spinalstenosis, spondylolisthesis). When the leg isstraightened, the sciatic nerve is placed under tension. An abnormal response should reproducethe patient’s radiating sciatic pain.

MANEUVER: The maneuver can be performed in theseated position or while supine. With the hip flexedat 90 degrees, the leg is gradually straightened.Adding passive dorsiflexion of the foot can en-hance the stretch.

INTERPRETATION: The straight leg raise maneuverusually is positive in patients with acute symptoms,occurring with acute HNP, compression fracture,epidural abscess or hemorrhage, or acute musclespasm atop spondylolisthesis or lateral recess en-croachment. Patients with chronic low back pain,uncomplicated osteoarthritis of the back, spinalstenosis, scoliosis, and minor disk bulges rarelyhave a positive response.

FIGURE 9–5. Perform the straight leg raise maneuver toscreen for radiculopathy.

PALPATE THE SACROILIAC JOINT

SUMMARY: The sacroiliac joint is hidden under thewing of the iliac crest. In order to create enoughpressure over the joint to cause pain, the joint mustbe palpated from a slightly medial position.

MANEUVER: The patient is placed prone. The PSISand the midline are marked with a pen. The areaof maximum tenderness is 1 inch medial and 1 inchinferior to the PSIS. Pressure is directed slightly lat-erally at a 70-degree angle.

INTERPRETATION: Tenderness directly over thesacroiliac joint is virtually pathognomonic of sacroil-iac strain and sacroiliitis. This must be distinguishedfrom the tenderness of the thoracolumbar fascia lo-cated superior to the sacroiliac joint and the sacralbony tenderness that is more midline and inferior ofthe sacroiliac joint.

FIGURE 9–6. Palpate the sacroiliac joint for local tenderness.


TRIAGE TO X-RAY For a patient who has a history oftrauma, has focal tenderness over a single vertebra, has se-verely impaired flexion by Schober measurement, has lost 1⁄2inch in height within 1 year, has a progressive neurodeficiton exam, or has acute back pain:

• Order posteroanterior (PA) and lateral views of the spinefor patients with a history of trauma or acute pain afterparoxysms of cough (fracture dislocation, transverseprocess fracture, compression fracture).

• Order PA and lateral views of the spine for patients withimpaired flexion or abnormal Schober measurement(ankylosing spondylitis, spinal stenosis).

• Order PA and lateral views of the spine for patients withfocal tenderness over a single vertebra (metastatic disease,epidural abscess, benign bony tumor).

• Order PA and lateral full spine views for patients with sco-liosis who have lost 1⁄2 inch in height in 6 months (pro-gressive scoliosis curve).

• Order PA, lateral, and oblique view of the spine for pa-tients with spondylolisthesis and worsening low backpain, sciatica, or both (progressive spondylolisthesisslippage).

• Order a standing anteroposterior (AP) pelvis for patientswith chronic low back pain and a short leg (low backstrain, sacroiliac strain, or degenerative arthritis aggravatedby leg length discrepancy).

TRIAGE TO THE LAB

• Order a complete blood cell count, erythrocyte sedimenta-tion rate, blood cultures, and nuclear medicine scan of thesacroiliac joints for patients with acute sacroiliac low backpain and peripheral arthritis (inflammatory spondylitis).

• Order a complete blood cell count, erythrocyte sedimen-tation rate, and blood cultures for patients with acutepain, fever, and rapidly progressive neurologic deficit (ver-tebral body osteomyelitis or epidural abscess).

CONSIDER A BONE SCAN For patients with focalspinous process tenderness, severe low back pain, progres-sive neurologic deficit, and a history of trauma or cancer(compression fracture, epidural metastasis).

CONSIDER MRI For patients with sensorimotor radicu-lopathy, cauda equina, increased symptoms from old com-pression fractures, advanced osteoarthritis with radiculopa-thy (large HNP, spinal cord tumor, compression fractureprogression, spinal stenosis).

CONSIDER ELECTROMYOGRAPHY For patientswith advanced lower extremity neurologic deficits that arevague in distribution or encompass more than one spinallevel or that are complicated by peripheral neuropathy(radiculopathy).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate low back pain and stiffness,minimally impaired overall movement of the back, inter-mittent mild sciatica, and a normal Schober test:

• Avoid lifting, twisting, and other physically demandingwork.

• Maintain straight, upright posture.• Apply ice to the muscle groups in spasm.• Perform daily passive stretching exercises in flexion.• Recommend a muscle relaxer over 7 consecutive nights.• Use a Velcro lumbosacral back brace during the daytime

(optional).

DETAILED EXAMINATION: SPECIFIC BACKDIAGNOSES

For patients with persistent or chronic symptoms, severeback pain and stiffness, focal spinous process tenderness,Schober measurement demonstrating less than 50% of nor-mal spinal flexion, intense paraspinal muscle spasm, orradiculopathy with motor involvement.

LUMBOSACRAL MUSCLE STRAIN Lumbosacral strain iscaused most often by the unaccustomed or improper use of themuscles that support the back (“back strain”). However, in the ab-sence of an obvious precipitating event, intense muscle spasm sug-gests the possibility of a potentially severe underlying spinalprocess. Any perceived threat to the integrity of the spinal column,nerves, or spinal cord initiates the protective spinal reflex, whichactivates the reactive muscle spasm. The Schober measurement ofspinal flexion combined with the direct palpation of the paraspinalmuscles provides the most objective means of determining the de-gree of lumbosacral strain.



SCHOBER MEASUREMENT

SUMMARY: Bending forward at the waist combinesthe movement of the lumbar spine including facetjoints, the lumbosacral ligaments, and the para-spinal muscles of the lumbosacral spine; movementof the sacroiliac joint; and flexion of the hips. TheSchober test objectively measures the contributionof the lumbosacral back to flexion. The Schobermeasurement is considered normal if the distancebetween the marks increases by 50% (from 10 to15 cm, or 5 to 71⁄2 inches depicted here), themarks gradually and smoothly move apart, and themaneuver does not incite back pain.

MANEUVER: The maneuver begins with the patientstanding. Two marks are made over the spine, oneat the level of the iliac crests and one at 10 cm.Then, the patient is asked to bend forward slowlyand to report when symptoms are felt. The tape is held at the upper mark. As the patient activelybends, the point at which pain occurs and the pointof maximum flexion are measured.

ADDITIONAL SIGNS: Paraspinal muscle tendernessand spasm, paraspinal muscle prominence, inabil-ity to lateral bend to the same degree side to side,and painful rotation of the lower back complete theassessment of lumbosacral strain.

INTERPRETATION: The Schober test provides arough gauge of the severity of the underlyingprocess affecting the lower spine. Its most practicaluse is to rule out significant structural and spinalpathology. A 50% increase in the measurement ef-fectively excludes significant back disease and isconsistent with sacroiliac strain, medical causes ofback pain, or drug-seeking patients feigning backpain. Measurements up to 14 cm are consistentwith mild to moderate lumbosacral strain from backstrain, scoliosis, spondylolisthesis, or moderate os-teoarthritis. Measurements up to 11 cm are consis-tent with ankylosing spondylitis, spinal stenosis, se-vere spinal nerve or spinal cord compression, andsevere reactive lumbosacral strain.

FIGURE 9–7. Perform a Schober measurement to assessspinal flexibility and lumbosacral strain.

LUMBAR RADICULOPATHY The diagnosis of lumbarradiculopathy is based on the patient’s description of “sciatica,”that is, a lower extremity lancinating pain accompanied by vary-

ing degrees of neurodeficit (e.g., paresthesia, hypesthesia); an exam-ination demonstrating impaired neurologic function; and abnor-malities on CT or MRI that correlate with the neurologic findings.



SUMMARY: Local anesthetic block is used to identifythe paraspinal muscles as the source of the patient’slumbosacral pain.

POSITIONING: Prone on the exam table.

SURFACE ANATOMY: Spinous processes, PSIS,paraspinal muscles, thoracolumbar fascia.

POINT OF ENTRY: Two inches from the midline di-rectly over the point of maximum tenderness.

ANGLE OF ENTRY: 90-degree angle.



ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL over theouter fascia of the muscle, 1⁄2 to 1 mL intramuscularly.

FIGURE 9–8. Local anesthetic block of the paraspinal mus-cles to confirm lumbosacral muscle strain.


STRAIGHT LEG RAISE

SUMMARY: The sciatic nerve arises from the lum-bosacral plexus and travels through the buttocks,behind the hip joint, within the body of the piri-formis muscle, through the popliteal fossa, anddown into the lower leg. At the level of the knee it branches as the tibial and common peronealnerves. Any pressure along the course of the nervecauses sciatica.

MANEUVER: The maneuver can be performed in the sitting or supine positions. The leg is graduallyextended either at the knee (while seated) or at thehip (while lying flat). The angle at which the pa-tient’s radicular pain is reproduced is noted. Calftightness or pain or pain behind the knee is notconsidered a positive response.

ADDITIONAL SIGNS: The patient often sits with ex-tended arms to reduce the pressure over the back.Percussion over the affected vertebra may repro-duce the patient’s pain. Neurologic abnormalitiescan include loss of sensation in the foot, reflexasymmetry, motor weakness and atrophy, and lossof bowel and bladder function.

INTERPRETATION: The straight leg raise maneuverusually is positive in patients with acute symptomsoccurring with acute HNP, compression fracture,epidural abscess or hemorrhage, or acute musclespasm atop spondylolisthesis or lateral recess en-croachment. Patients with chronic low back pain,uncomplicated osteoarthritis of the back, spinalstenosis, scoliosis, and minor disk bulges rarelyhave a positive maneuver.

FIGURE 9–9. Perform a straight leg raise maneuver to evalu-ate for acute or subacute sciatica or lumbar radiculopathy.

CT IMAGING

CASE: The patient experienced acute low back painafter lifting a large audio speaker. Flexibility gradu-ally decreased. Within 36 hours the patient com-plained of pain radiating down the left leg accom-panied by numbness of the bottom of the foot.

DIAGNOSIS: Acute disk herniation at L5–S1 with compression of the S1 nerve root in the lateralrecess.

DISCUSSION: Lumbar radiculopathy is graded ac-cording to the degree of neurologic deficit. Seventy-five percent to 80% of cases are limited to impair-ment of sensation in a dermatomal distribution(sensory deficit only), 20% to 25% involve impair-ment of both sensation and motor function (sensori-motor deficit), and less than 1% of patients haveimpairment of bowel and bladder function (sensori-motorvisceral or cauda equina syndrome). CTimaging is indicated for persistent or progressivesensory loss or sensorimotor loss with or withoutcauda equina syndrome.

FIGURE 9–10. CT imaging to confirm the cause of lumbarradiculopathy.

CAUDA EQUINA SYNDROME Cauda equina syndrome isthe neurologic condition affecting the lowermost segments of thecord, the sacral nerves. Large herniated disks, disk fragments,sacral tumors, and primary spinal cord tumors cause loss of

sensation in the perineal area (“saddle anesthesia”), loss of boweland bladder control, or neurogenic bladder. The definitiveanatomic diagnosis always includes CT or MRI.


RECTAL SPHINCTER TONE AND WINK SIGNAND PERINEAL SENSATION

SUMMARY: The combination of loss of sensation inthe perineal area (saddle anesthesia), loss of boweland bladder control, and bilateral lower extremityneurologic impairment is called cauda equina syn-drome. Large herniated disks at the lower lumbarareas can cause the complete syndrome. Sacral tu-mors and primary spinal cord tumors can presentwith isolated bowel and bladder impairment.

MANEUVER: The patient is placed in the lateral decu-bitus position with the hips and knees flexed to 90 de-grees. Rectal sphincter tone is performed on rectal ex-amination. The rectal sphincter wink sign is performedby scratching the perianal skin and observing or feel-ing the reflex contraction of the rectal sphincter.

ADDITIONAL SIGNS: Sensory testing of the skin ofthe perineal areas shows diminished light touchand pain sensation. Reactive paraspinal musclespasm may be present. Evidence of lower extremityneurologic deficit may be present. Abnormalities ofbladder function are present on cystometrograms.

INTERPRETATION: Patients suspected of having caudaequina syndrome should undergo immediate radio-graphic imaging and emergent referral to the neuro-surgeon. Delay in evaluating patients with bowel andbladder involvement increases the risk of permanentloss of control of these vital organ functions.

FIGURE 9–11. Rectal sphincter tone and wink sign andperineal sensation are used to define impairment of the lowersacral nerves.

CT IMAGING

CASE: The 53-year-old patient had a history ofchronic low back pain and intermittent sciaticadown the right leg. His symptoms changed acutelyafter a violent episode of coughing. The examshowed bilateral sensory deficits, weakness of bothlegs, urinary incontinence, and decreased rectalsphincter tone with bowel leakage.

DIAGNOSIS: Acute disk herniation at L5–S1 with compression of the S1 nerve root in the lateral recess.

DISCUSSION: The three stages of cauda equinasyndrome include chronic backache, sciatica, andacute bilateral leg weakness and incontinence.Most cases are caused by large extruded disk her-niation with fragmentation. Emergent CT or MRI ismandatory in the third stage.

FIGURE 9–12. CT imaging to confirm the cause of lumbarradiculopathy.


scoliosis—are associated with dramatic loss of mobility, chronicmuscle strain, and lumbar radiculopathy. The diagnosis often isassumed based on age and stiffness, but confirmation includesplain x-rays, CT scanning, or MRI.

OSTEOARTHRITIS OF THE LUMBOSACRAL SPINEOsteoarthritis of the lumbar spine is a universal phenomenon. Themildest forms are associated with chronic back ache (“lumbago”)and early morning stiffness. However, severe involvement—diffuseidiopathic skeletal hyperostosis, spinal stenosis, and osteoarthritic

FUNCTIONAL STIFFNESS

SUMMARY: Observation of the patient’s generalmovement often provides the most important clue to overall back function. Ever greater degrees of os-teoarthritis create ever greater difficulties in chang-ing position, flexing at the waist, and arising froma sitting position.

MANEUVER: Simple observations are made of thepatient’s ability to stand, walk in the room, climbonto and off of the exam table, and change from a lying to a sitting position.

ADDITIONAL SIGNS: The Schober test provides themost objective measurement of the loss of flexibilityof the back. The normal lumbar lordosis is replacedwith a straightening of the lumbar curve or a re-placement with a scoliosis curve. Paraspinal musclespasm can be intense. Various degrees of impairedneurologic function of the lower extremity may bepresent.

INTERPRETATION: Observations on the generalmovement of the back and measurement of theSchober test provide the best overall assessment ofthe impact of lumbosacral osteoarthritis. However,plain x-rays are needed to distinguish the degree of osteoarthritic change from the impairment offunction caused by reflex muscle spasm.

FIGURE 9–13. Osteoarthritis of the spine does not have a spe-cific sign; it is more of a functional stiffness suggested by themannerisms of the patient.


SPINAL STENOSIS The diagnosis of spinal stenosis is sug-gested by a history of extensive osteoarthritis, chronic lumbosacralsymptoms, and documentation of extreme limitation of motion,with the Schober test demonstrating a loss of more than 75% offlexion. Confirmation of the diagnosis includes MRI that demon-

strates the following: a narrowed AP diameter (less than 10 mm),deformed lateral recesses (loss of the normal heart-shaped canal),and spinal cord compression at the spinal level that correlates withthe patient’s symptoms and signs.

POSTEROANTERIOR RADIOGRAPH OF THELUMBOSACRAL SPINE

CASE: This 63-year-old salesperson complained oflow back pain over many years and a gradual lossof flexibility. He denied any prior trauma. He hadnot experienced any pain down the leg, loss oflower extremity sensation, coordination, or strength,or difficulties with bowel and bladder function. Thepatient exhibited a general stiffness when movingin the exam room. He used his arms to pushagainst his upper thigh when arising from a seatedposition. The paraspinal muscles were rock hard,and his Schober measurement was 10 to 11 cm, oronly 20% of normal.

DIAGNOSIS: Forestier’s disease or diffuse idio-pathic skeletal hyperostosis (DISH syndrome).

DISCUSSION: DISH is characterized by the exuber-ant formation of osteophytes along four contiguousvertebra. Contrast this with the bridging syndesmo-phytes of ankylosing spondylitis leading to the bam-boo spine deformity. Osteophytes extend laterallybefore turning up or down to the adjacent vertebra.Syndesmophytes (paravertebral ossifications) extendvertically, following the course of the ligaments.

FIGURE 9–14. PA radiograph of the lumbosacral spine to con-firm degenerative osteoarthritis.


SCHOBER TEST

SUMMARY: Facet joint osteophyte formation, hy-pertrophy of the ligamentum flavum, and the irreg-ularities caused by the collapse of the vertebraldisks combine to cause a gradual stenosis of thespinal column and a gradual impairment of lum-bar flexibility.

MANEUVER: See Figure 9–7 for details.

ADDITIONAL SIGNS: The straight leg raise maneu-ver often is equivocal because of the slowly pro-gressive chronic process. The normal lumbar lordo-sis is replaced with a straightening of the lumbarcurve. Paraspinal muscle spasm can be intense.Percussion over the affected vertebra may repro-duce the patient’s pain. Neurologic abnormalitiesinclude loss of sensation in the foot, reflex asymme-try, motor weakness, and atrophy but rarely caudaequina symptoms.

INTERPRETATION: MRI is needed to confirm the di-agnosis of spinal stenosis and distinguish it fromankylosing spondylitis, DISH syndrome, and the se-vere reflex muscle spasms that can accompany ad-vanced scoliosis or spondylolisthesis.

FIGURE 9–15. Spinal stenosis is strongly suggested by aSchober test combined with plain x-rays of the back demonstrat-ing advanced osteoarthritic changes.

MRI

SUMMARY: MRI is used to measure the AP diameterof the spinal column and determine which lumbarlevel has the greatest spinal cord or spinal nervecompression.

CASE: This 73-year-old retired nurse complained ofsevere intermittent right lower leg pain whenevershe stood too long or walked. Her symptoms oc-curred predictably after 20 minutes of standing orwalking approximately 1 block. Her straight legraise maneuver was negative. Her dorsiflexion wasweak, and the circumference of her calf was 3⁄4inches smaller on the right side.

DIAGNOSIS: Spinal stenosis at L4–L5 and L5–S1levels.

INTERPRETATION: The indication for decompressionlaminectomy requires a documentation of spinalstenosis on MRI, a correlation of the patient’s painpattern with the neurologic deficits found on exami-nation, and a correlation of the neurodeficits onexam with the objective radiographic findings.

FIGURE 9–16. MRI to confirm spinal stenosis.


SCOLIOSIS Patients with significant thoracolumbar scoliosisare examined for a change in height, the degree of reactive musclestrain, the presence of radiculopathy, and impairment of pul-

monary function. A decline in height of 1⁄2 inch or more in a 6- to12-month period of time is the primary indication for repeat, full-length, standing radiographs of the spine.

SERIAL HEIGHT MEASUREMENT

SUMMARY: The patient’s height is determined byposture, vertebral body and vertebral disk integrity,alignment of the thoracic and lumbosacral spines,and the presence of a scoliosis curve.

MANEUVER: Serial measurements of height aretaken at 6- to 12-month intervals. Ideally, thesame scale or wall measurements should be used over time.

ADDITIONAL SIGNS: The normal lumbar lordosis is replaced with a straightening of the lumbarcurve. Paraspinal muscle spasm can be intense. The Schober test of lumbar flexibility is reduced.Typically the patient has measurements of 10 to 13 cm, depending on the degree of muscle spasm.If the patient has a rotatory component to thecurve, flexion at the waist will cause a paraspinalhump (prominent paraspinal muscles along oneside of the spine).

INTERPRETATION: Progressive angulation of the sco-liosis curve leads to an inevitable loss of overallheight.FIGURE 9–17. Serial height measurement is the single most

important objective measurement for the patient with scoliosis.

POSTEROANTERIOR LUMBOSACRAL SPINE X-RAYS

SUMMARY: Serial PA lumbosacral spine films areused to assess the stability or progression of thescoliosis curve. Repeat x-rays are indicated when-ever the patient’s height decreases by 1⁄2 inch.

TECHNIQUE: Standing full-length x-rays includingthe sacrum, lumbar vertebra, and thoracic vertebraare obtained. Lines are drawn parallel to the end-plates of the vertebra at the each end of the curve.Next, perpendicular lines are drawn so that they in-tersect close to the vertebral column. The scoliosisangle is measured between these intersecting lines.

INTERPRETATION: Progressive angulation warrants re-ferral to the spine specialist for possible stabilization.

FIGURE 9–18. Full-length posteroanterior lumbosacralspine x-rays are used to measure the S-shaped curvature of scoliosis.


SPONDYLOLITHESIS Spondylolisthesis causes varying de-grees of recurrent and chronic low back pain, lumbosacral musclestrain, or slowly progressive radiculopathy. The diagnosis is sug-gested by a palpable step-off sign at the spinous processes, but stan-

dard radiographs of the lumbosacral spine are needed to confirmthe diagnosis. The step-off sign correlates with the anterior slippageof one vertebral body relative to another, as seen on the lateral pro-jection of the spine.

INSPECT AND PALPATE THE SPINOUSPROCESSES

SUMMARY: Spondylolisthesis, an anterior slippageof one vertebral body on another, is caused by a defect in the pars interarticularis portion of thevertebrae. Although this condition can be acquiredthrough injury, most cases are congenital. The signsand symptoms are nonspecific. Confirmation of thediagnosis depends on objective x-ray changes.

MANEUVER: Advanced cases may show spinousprocess tenderness (depicted here) or the classicstep-off at the site of the spondylolisthesis.

ADDITIONAL SIGNS: The Schober test provides themost objective measurement of the loss of flexibilityof the back. The normal lumbar lordosis is replacedwith a straightening of the lumbar curve or replace-ment with a scoliosis curve. Paraspinal musclespasm can be intense. Various degrees of impairedneurologic function of the lower extremity may bepresent.

INTERPRETATION: Grading of spondylolisthesis canbe based on function, flexibility, the presence or absence of accompanying radiculopathy, or radio-graphic criteria. Repeat x-rays are necessary for pa-tients with progressive loss of flexibility, greater de-grees of paraspinal muscle spasm, and progressiveradicular symptoms. Progression from one grade tothe next is an indication for surgical stabilization.

FIGURE 9–19. Inspect and palpate the spinousprocesses of the lumbosacral curve for the step-off sign ofspondylolisthesis.

X-RAYS

CASE: This 40-year-old man suffered chronic lowback pain for years. The patient denied radicularpain, loss of muscular strength, or change in boweland bladder symptoms. The Schober measurementof flexion was 10 to 13 cm.

DIAGNOSIS: Grade II spondylolisthesis of L5 on S1.Secondary osteoarthritic changes in the facet jointsof L4 and L5.

DISCUSSION: Spondylolisthesis is graded accordingto the degree of anterior displacement: Grade I, upto 1⁄4 of the length of the vertebral body; Grade II,between 1⁄4 and 1⁄2; Grade III, more than 1⁄2; andGrade IV, anterior to the vertebral body.

FIGURE 9–20. X-rays to measure the anterior migration of thevertebral body and stage the degree of spondylolisthesis.


COMPRESSION FRACTURE Compression fracture of thevertebral body is characterized by focal tenderness directly over thespinous process, severe lumbosacral muscle spasm, and dramatic

loss of spine flexibility. Bone scanning or MRI is needed to distin-guish an acute fracture from a previous healed fracture.

COMPRESSION FRACTURE

SUMMARY: The vertebral body is susceptible to thecompressive forces that result from falls, hyperflexioninjuries, or paroxysms of cough, especially when thepatient suffers from generalized osteoporosis.

MANEUVER: Each of the five spinous processes ispalpated. If the patient’s pain is not reproduced bysimple palpation, then each of the five lumbar lev-els is percussed using a reflex hammer or the bluntside of the fist.

ADDITIONAL SIGNS: As with any acute process,the following signs may be present. The Schobertest demonstrates severe impairment of flexibility;typical measurements of 10 to 11 cm. Paraspinalmuscle spasms can be unilateral or bilateral andusually are intense. Neurologic abnormalities in-cluding loss of sensation in the foot, reflex asymme-try, motor weakness and atrophy, and caudaequina symptoms can accompany the fracture.

INTERPRETATION: Because the abnormal signs onexamination of the back overlap with those of os-teomyelitis, epidural abscess, and metastatic cancerof the vertebral body, it is imperative to confirm thediagnosis of simple compression fracture by specialradiographic studies. If the compression fracture oc-curs after coughing, hyperflexion injury, or minortrauma, the patient should be evaluated for osteo-porosis by bone densitometry.

FIGURE 9–21. Palpate the spinous process for the focaltenderness of compression fracture.

BONE SCANNING OR MRI

CASE: The patient experienced acute low back painafter falling directly on the buttock in the shower.The pain remained in the center of the back.Movement of any kind became progressively morepainful and stiff. Point tenderness was present at L1.

DIAGNOSIS: Acute compression fracture of L1 withreactive paraspinal muscle spasm causing an ac-quired S-shaped curve.

DISCUSSION: Point tenderness over a spinousprocess after trauma usually is caused by compres-sion fracture. Plain x-rays will demonstrate the per-centage loss of vertebral height (measured alongthe anterior portion of the vertebral body). Radio-graphic imaging with bone scanning or MRI willconfirm whether this is a new or old fracture.

FIGURE 9–22. Plain x-rays cannot distinguish an old fracturefrom an acute fracture. Bone scanning or MRI is used to deter-mine whether the compression fracture is new.


EPIDURAL PROCESS The epidural space can be compromisedby tumor, infection, or hemorrhage. Acute swelling in this small,confined area causes localized deep pain, focal spinous process ten-

derness, severe lumbosacral muscle spasm, and neurologic signsthat can evolve rapidly. In order to avoid irreversible neurologicdamage, the diagnosis must be made promptly by MRI.

PALPATE AND PERCUSS THE SPINOUSPROCESSES

SUMMARY: The posterior spinous processes are theonly accessible bony prominences available for direct palpation.

MANEUVER: Each of the five spinous processes ispalpated. If the patient’s pain is not reproduced bysimple palpation, then each of the five lumbar lev-els is percussed using a reflex hammer or the bluntside of the fist.

ADDITIONAL SIGNS: The Schober measurementdemonstrates severe impairment of flexibility; typi-cal measurements are 10 to 11 cm. Unilateral orbilateral paraspinal muscle spasms, often in cramp-like waves are present. Neurologic abnormalitiesincluding loss of sensation in the foot, reflex asym-metry, motor weakness and atrophy, and caudaequina symptoms can evolve rapidly.

INTERPRETATION: Painful spinous processes are seenwith fracture, primary and secondary bony disorders,and rarely osteoarthritis. Percussion pain is more char-acteristic of radiculopathy from HNP or spinal stenosis.

FIGURE 9–23. Palpate and percuss the spinousprocesses for intrinsic disease of the spinal column.

MRI

CASE: The patient was diagnosed with large cellcarcinoma of the lung. During the course ofchemotherapy he developed low back pain that became progressively more severe. After a severecoughing episode, he suddenly became paralyzedbelow the waist. Prompt institution of radiation ther-apy to the back failed to reverse the paralysis.

DIAGNOSIS: Metastatic large cell carcinoma of thelung to the L2 and L3 vertebral bodies with exten-sion into the epidural space and compression of thespinal cord.

DISCUSSION: Patients with a known history of can-cer presenting with new back pain must be evalu-ated emergently and undergo radiographic imag-ing expeditiously.

FIGURE 9–24. MRI is the test of choice if an epidural process issuspected on clinical grounds.


SACROILIAC STRAIN AND SACROILIITIS Symptomsarising from the sacroiliac joint vary widely and consist of local-ized low back pain, secondary lumbosacral muscle spasm, re-ferred pain mimicking radiculopathy, or a combination of these

symptoms. The diagnosis requires the demonstration of focal tenderness over the joint. The area of maximum tenderness islocated 1 inch medial and 1 inch inferior to the posterior supe-rior iliac spine (PSIS).

SACROILIAC JOINT

SUMMARY: The sacroiliac joint is located 1 inch me-dial and 1 inch inferior to the PSIS. In order to repro-duce the patient’s pain, pressure is applied over thejoint and directed in a downward and slightly out-ward direction (the ilium lies directly over the joint).

MANEUVER: The patient is placed in the prone posi-tion. Local tenderness over the sacroiliac joint is com-pared with the adjacent bones (sacrum and iliaccrest) and the origin of the erector spinae muscle.

ADDITIONAL SIGNS: The Patrick maneuver, alsocalled the Faber maneuver (flexion, abduction, andexternal rotation of the hip), can reproduce thepain of moderate to severe sacroiliac strain andsacroiliitis. Compression of the pelvis against theexam table with the patient in the lateral decubitusposition occasionally is positive.

INTERPRETATION: Local tenderness is mild to moder-ate with sacroiliac strain, the most common condi-tion affecting the joint. Moderate to severe tender-ness is characteristic of sacroiliitis seen with theinflammatory spondyloarthropathies (e.g., Reiter’sdisease, ankylosing spondylitis).

FIGURE 9–25. Palpate the sacroiliac joint for tenderness.


OBJECTIVE: Local anesthetic block is used to confirminvolvement of the sacroiliac joint.

TECHNIQUE: Enter 1 inch caudal to the PSIS and 1 inch lateral to the midline; advance at a 70-degree angle to the firm resistance of the posteriorsupporting ligaments.

NEEDLE: 11⁄2 inch or 31⁄2 inch, 22 gauge.

DEPTH: 11⁄2 to 21⁄2 inches.

VOLUME: 1 to 2 mL local anesthetic, 1 mL K40, orboth.

NOTE: The injection should be placed flush againstthe periosteum at the junction of the sacrum and theileum at the maximum depth.

FIGURE 9–26. Local anesthetic block to confirm the involve-ment of the sacroiliac joint.


COCCYDYNIAFocal tenderness at the sacrococcygeal junction (by direct palpationor bimanual rectal examination) is the hallmark feature of coccy-dynia. However, before concluding that this is a local muscu-

loskeletal condition, it is necessary to rule out rectal or pelvic disor-ders by performing a complete examination of the lower colon, rec-tum, and pelvis.

PALPATE THE SACROCOCCYGEAL JUNCTION

OBJECTIVE: The majority of cases of coccydynia occur in women. Most cases are the result of child-birth. The remaining cases usually are the result ofdirect trauma from falls.

MANEUVER: The patient is placed in the lateral de-cubitus position with the hips and knees flexed to90 degrees. The sacrum is identified, and the ex-aminer palpates down the sacrum until the sacro-coccygeal junction is met. Tenderness should bemaximum at this point.

ADDITIONAL SIGNS: Bimanual examination of thecoccyx with one finger in the rectum and one fingergrasping the coccyx is extremely painful. In placeof the normal curvature of the sacrum and coccyx,the coccyx can be acutely angulated. The remain-ing examination of the rectum and pelvis is normal.

INTERPRETATION: The diagnosis of coccydynia isstraightforward. The only pitfall in evaluating thepatient with a painful coccyx is making sure thelower colon and pelvis are thoroughly evaluatedbefore concluding that the process is of a localmusculoskeletal origin.

FIGURE 9–27. Palpate the sacrococcygeal junction toevaluate coccydynia.


SUMMARY: Local anesthetic block is used to confirmthe sacrococcygeal joint as the source of the pa-tient’s buttock pain.

TECHNIQUE: Enter 1 inch caudal to the sacrococ-cygeal junction in the midline; the needle is ad-vanced at a 70-degree angle to the firm resistanceof the posterior supporting ligaments or the hard resistance of bone.



VOLUME: 1 to 2 mL local anesthetic, 1 mL D80, orboth.

NOTE: The injection should be placed flush againstthe supporting ligaments or the periosteum of thesacrum.

FIGURE 9–28. Local anesthetic block to confirm involvementof the sacrococcygeal joint.


BACK PAIN REFERRED FROM THE ABDOMEN Lowback pain unassociated with focal back tenderness, impairment inflexibility, low back stiffness, or radicular symptoms suggests the

possibility of referred pain from the retroperitoneum (e.g., pyelonephritis, renal colic, retrocecal appendix, cecal carcinoma, pelvic tumor, abdominal aneurysm).

PALPATE THE ABDOMEN

SUMMARY: Any of the retroperitoneal structures cancause back pain. Pyelonephritis and nephrolithiasisare the two most common conditions presentingwith a significant component of back pain. Withthe exception of the early presentations of tumors of the retroperitoneum (including ascending and descending colon cancer) and abdominal aorticaneurysm, most of the conditions have associatedsymptoms that suggest a medical cause of referredpain to the back.

MANEUVER: A full examination of the abdomenand pelvis is necessary if a medical cause of re-ferred pain to the back is suspected. Examinationof the entire vascular tree including the abdominalaorta (for local tenderness and bruits), the iliac andcommon femoral arteries, and the foot and anklearteries should be performed if the patient has riskfactors for peripheral vascular disease.

INTERPRETATION: Any patient who lacks local backtenderness, paraspinal muscle spasm, impairedflexibility, or sacroiliac tenderness should be evalu-ated for a medical cause of referred back pain.

FIGURE 9–29. Palpate the abdomen for dilation and tender-ness of the abdominal aorta.

SPIRAL CT IMAGING

CASE: This 50-year-old woman presented withacute, cramplike back pain. The pain was so se-vere that she could not find a comfortable positionon the exam table. Examination disclosed tender-ness at the right costovertebral angle, moderatepain to percussion over the paraspinal muscles, but no tenderness or loss of flexibility in the back.Urinalysis demonstrated microscopic hematuriawithout signs of active infection.

DIAGNOSIS: Right urethral stone with secondary hydronephrosis of the right kidney. Normal size abdominal aorta.

DISCUSSION: The colicky pain of nephrolithiasismimics the cramplike pain of an epidural abscess.However, renal colic does not cause paraspinalmuscle spasm or dramatic loss of lumbar spine flexibility as measured with the Schober test.

FIGURE 9–30. Spiral CT imaging to evaluate the retroperi-toneal structures.


Examination Signs Diagnosis ConfirmationTender paraspinal muscles 1. Lumbosacral strain Local anesthetic placed within the paraspinal muscles

(optional)

Schober: 60–70% of normal spinal flexion

Painful and limited flexion and lateral bending

No evidence of radiculopathy or structural back disease

� Straight leg raise maneuver 2. Lumbar radiculopathy CT or MRI demonstrating nerve compression (necessary if motor signs are present)



Abnormal lower extremity neurologic exam

Incontinence Cauda equina syndrome MRI, cystometrogram

Perineal hypesthesia

Loss of rectal tone

Spastic bladder

Chronic stiffness with an otherwise normal exam Osteoarthritis X-rays, CT, or MRI of the back

Schober: impairment or flexion depends on the extent of the arthritis

Paraspinal muscle spasm with a minor degree of tenderness

Chronic sciatica with equivocal straight leg Spinal stenosis CT or MRI of the backraise; progressive


Rigid paraspinal muscles with a minor degree of tenderness

S-shaped curve to the back Scoliosis AP view of the entire back for scoliosis curve measurement

Paraspinal hump when flexing

Decreasing height measurements

Variable degree of lumbosacral strain

Loss of the normal lumbosacral lordotic curve Spondylolisthesis Lumbosacral back x-raywith step-off

Variable degrees of lumbosacral strain

Focal percussion tenderness over a single Compression fracture, Lumbosacral back x-ray, MRIvertebral body metastatic bony lesion,

epidural abscess


Severe muscle tenderness and spasm

Focal percussion tenderness over a single Epidural abscess MRIvertebral body


Severe muscle tenderness and spasm

Low-grade fever, mildly elevated complete blood cell count, prostration

Local tenderness over the sacroiliac joint Sacroiliac strain, sacroiliitis Oblique views of the pelvis, scan of the sacroiliac joints

Patrick maneuver produces pain over the sacroiliac joint when acute or severe

Lateral pelvic compression causes pain over the sacroiliac joint when acute or severe

Tenderness at the sacrococcygeal junction Coccydynia Local anesthetic placed at the sacrococcygeal junction

Normal rectal, pelvic, and colon exams



• The diagnosis of lumbar radiculopathy relies heavily onthe patient’s description of pain. Sciatica must be distin-guished from the referred pain of hip arthritis andtrochanteric bursitis. The pain of classic sciatica radiatesfrom the buttocks, past the knee, to the foot. In mostcases it is associated with paresthesia or hypesthesia inthe foot. Referred pain from the hip rarely extends pastthe knee. In general, any pain that crosses two consecu-tive joints is neurogenic in origin until proven otherwise.

• Assessment of the patient presenting with lumbarradiculopathy entails identification of the nerve rootthat is most responsible for the patient’s symptoms. Tothis end, the patient’s description and location of thesciatic pain is one of the best clues used in correlatingsymptoms and the exact anatomic process. The L5 root,located at the L4 and L5 level, radiates down the lateralaspect of the leg. The S1 root, located at the L5 and S1level, radiates down the posterior aspect of the leg.

• The straight leg raise maneuver is the most consistentsign of acute or subacute nerve root irritation. A nega-tive straight leg raise maneuver rules out an acuteprocess involving compression of a nerve root or spinalcord. In contrast, the straight leg raise maneuver mustbe interpreted with caution in the case of chronic lum-bar radiculopathy. The maneuver often is negative withspinal stenosis or the radiculopathy associated withspondylolisthesis.

• Greater degrees of spinal nerve root compression causea progressive lower extremity neurodeficit. Loss of sen-sation in the foot is followed by dysesthetic pain, loss ofthe reflex arc, loss of resting muscle tone and weakness,muscle atrophy, and loss of bowel and bladder sensa-tion and muscle tone. Similarly, recovery of neurologicfunction usually follows the same order, just in reverse.

CLINICAL PEARLS

• Seventy-five percent to 80% of lumbar radiculopathy islimited to sensory symptoms. The prognosis in thesecases is uniformly favorable, as opposed to that of pa-tients with motor involvement or bowel and bladderdysfunction. Therefore, emphasis is placed on deter-mining subtle changes in the reflex arc, motor strength,and bowel and bladder tone. The earliest change in re-flex arc testing is a difference in the thresholds of the re-flex. The earliest change in muscle strength is an inabil-ity to perform repeated dorsiflexion or plantarflexion(i.e., a loss of endurance).

• Patients with lumbar radiculopathy with symptoms andsigns limited to sensory changes respond to conservativetreatment with rest, ice, stretching, a muscle relaxer, andtime. Special testing usually is not indicated unlesssymptoms and signs fail to improve over several weeks.

• Patients with lumbar radiculopathy involving motor,bowel, or bladder symptoms and signs should be evalu-ated with special imaging studies. If symptoms andsigns are acute and evolving (e.g., large disk, epiduralprocess, hemorrhage), imaging must be performed im-mediately and neurosurgical consultation made emer-gently.

• A normal Schober measurement combined with averagetone of the paraspinal muscles of the lumbosacral spinevirtually rules out a significant structural or neurologicprocess. Attention is then turned to evaluating theretroperitoneal area as a source of the patient’s com-plaint (e.g., pyelonephritis, nephrolithiasis, pancreatitis,aortic aneurysm, pelvic pathology).

• The sequential height measurement is the single mostimportant variable when following a patient with scol-iosis, spondylolisthesis, osteoporosis, or spinal stenosis.

172

CHAPTER 10: HIP


Diagnoses

Hip bursa (most common)Trochanteric bursitisGluteus medius bursitisIschiogluteal bursitisIliopectineal bursitisSnapping hip

Hip jointOsteoarthritisInflammatory arthritisSeptic arthritisShallow acetabulumSubluxation or dislocation

Hip prosthesisLooseningProsthesis fractureSubluxation or dislocation

Meralgia paresthetica

Bony disordersAvascular necrosis of the hipOccult fracture of the femoral neckMalignancy

Referred painLumbosacral spineSacroiliac jointVascular occlusive diseaseInguinal hernia

Confirmations

Local anesthetic blockLocal anesthetic blockLocal anesthetic blockLocal anesthetic blockExamination

X-ray: standing anteroposterior (AP) pelvisAspiration and synovial fluid analysisAspiration, synovial fluid analysis, and cultureX-ray: standing AP pelvisX-ray: AP pelvis

X-ray: bone scanX-ray: hip seriesX-ray: hip series

History, sensory examination

Bone scan, magnetic resonance imaging (MRI)Bone scan, MRIBone scan, MRI

Neurologic exam, computed tomography scanningX-ray, bone scanningExamination, Doppler studyExamination

INTRODUCTION The hip is a ball-and-socket jointformed between the proximal end of the femur and the ac-etabular fossa of the pelvis. It is supported by a synovialmembrane, a layer of supporting ligaments, and the largestgroup of muscles of the body: the gluteus muscles posteri-orly, the quadriceps and iliopsoas muscles anteriorly, andthe adductors medially. Understanding the conditions thataffect the hip entails an appreciation of four unique charac-teristics of the joint: the unusual 135-degree angle betweenthe femur and the acetabulum (the asymmetrical pressureplaced over the articular cartilage increases the risk of os-teoarthritis), the skeletal friction created between the femurand the body’s largest group of supporting muscles (the fric-tion is countered by the body’s largest aggregate concentra-tion of lubricating bursal sacs, the trochanteric, gluteusmedius, ischiogluteal, and iliopectineal bursitis), the depen-dence of the movement of the hip on the adjacent sacroil-iac (SI) joint and lower back (the common overlap of hipbursitis and lower back disorders), and the hip’s unique andprecarious dual blood supply (interference of the ligamentteres supplying the proximal third of the femoral head orthe haversian system located in the medulla of the femursupplying the distal third of the femur can lead to os-teonecrosis of the femoral head).

Bursitis dominates the differential diagnosis of hip pain.Trochanteric and gluteus medius bursitis are caused by thefriction between the gluteus medius tendon, the tensor fas-cia lata, and the trochanteric process of the femur.Ischiogluteal bursitis is caused by the friction between thebiceps femoris and the ischium of the pelvis. Iliopectinealbursitis, the least common of the four bursal inflamma-tions, is caused by the friction between the iliopsoas and theiliopectineal line of the pelvis.

Osteoarthritis of the hip is the second most commoncondition. Patients with genetic predisposition (positivefamily history of arthritis), previous hip or femur fractures,dislocations, rheumatoid arthritis, or shallow acetabuli areat particular risk. The 135-degree angle of articulation cre-ates an uneven pressure over the acetabular surface.

Meralgia paresthetica, a compression neuropathy of thelateral femoral cutaneous nerve, causes dysesthetic pain orhypesthesia over the upper outer thigh. It is included as ahip condition simply because of the location of its symp-toms. Strictly speaking, it is not directly related to the in-trinsic conditions affecting the hip.

In general, trauma does not play a major role in thepathogenesis of most of the common conditions affectingthe hip. Osteoarthritis, the various forms of hip bursitis,and meralgia paresthetica rarely result from direct trauma.However, patients with significant osteoporosis who fallare at risk for occult hip fracture, a nondisplaced crackthrough chronically weakened bone. If occult fracture issuspected, the patient must be evaluated and treated just asis the patient with major trauma and referred to the frac-ture specialist.

Finally, pain can be referred to the hip knee from thelower lumbar nerve roots, from the SI joint, or from occlu-sive disease of the distal aorta and iliac arteries. Lumbarlevel L4–L5 and lumbar level L5–S1 cause pain and numb-ness that typically course through the hip either laterally orposteriorly, respectively. Moderate to severe sacroiliitis of-ten refers pain into the lower buttocks and upper outer

thigh areas. Aortoiliac occlusive disease (Leriche’s syndromeof buttock claudication and impotence) classically referspain into the buttock and upper outer thigh areas.

SYMPTOMS The description, character, and location ofthe patient’s pain are the key elements in the differential di-agnosis of hip pain. Patients with bursitis and meralgiaparesthetica complain of pain and irritation over a well-defined area of the lateral thigh. By contrast, patients withprimary involvement of the hip joint describe “groin” painlocated in a ill-defined area anteriorly. Diffuse posterior hippain is the least common pain pattern and is most com-monly referred from the gluteus medius bursa, lumbosacralspine, or SI joint.

Lateral hip pain aggravated by direct pressure is the clas-sic pain pattern of trochanteric and gluteus medius bursitis.Because all bursae are pressure sensitive, greater degrees ofinflammation and swelling result in more intense pressure-induced symptoms. Pressure sensitivity ranges from mildmorning pain and stiffness to intolerance of sleeping on theaffected side.

Progressive lateral hip pain aggravated by direct pres-sure and weight bearing can also be seen with the involve-ment of the bony femur. Although bursitis is 100 timesmore common than involvement of the bone, patients witha history of adenocarcinoma who present with lateral hippain must be evaluated by special radiographic testing (e.g.,bone scanning, MRI).

Lateral hip pain associated with paresthesia and hypes-thesia is the classic combination of symptoms seen withmeralgia paresthetica. Meralgia paresthetica is characterizedby a localized area of a pain (often described as a burningpain or a uncomfortable heightened sensation) that is notinfluenced by direct pressure, movement of the hip, ormovement of the lower back. By contrast, lumbar radicu-lopathy, particularly at the L4 spinal root (L4–L5 diskspace), causes lateral hip pain and sensory abnormalitiesthat commonly extend over a much wider area includingthe knee, calf, and foot.

Anterior hip pain (“groin pain”) is the classic conditionaffecting the hip joint. When anterior pain is associatedwith the gradual loss of internal and external rotation, os-teoarthritis is the most likely diagnosis. By contrast, whenanterior pain develops acutely, weight bearing is poorly tol-erated, and internal and external rotation are dramaticallyimpaired, special testing must be performed for the follow-ing conditions: AVN (vascular risk factors), occult fracture(trauma), acute synovitis (known as inflammatory arthritis),or the uncommon septic arthritis (when systemic symptomsare present).

Anterior hip pain that is aggravated by neither directpressure nor flexion of the hip suggests inguinal hernia,lower abdominal disorders, or the uncommon referred painfrom the higher lumbar spinal nerve roots (L2 and L3 spinallevels).

Posterior hip pain (“gluteal”) is the least common painpattern and is either caused by gluteus medius bursitis or re-ferred from lumbosacral nerve roots, the SI joint, or thenerve infected by herpes zoster (shingles). Patients describ-ing pain in the gluteal area should undergo a thorough ex-amination of the lumbosacral spine, SI joint, and hip. This

HIP 173


often includes special radiographic testing of these areas inorder to define the exact anatomic cause.

Finally, patients presenting with anterior hip or thighpain localized to the midthigh pose the greatest clinicalchallenge. Primary disease of the hip joint, primary and sec-ondary lesions of the upper femur, stress fracture of thefemoral neck, and radiculopathy arising from the higherlumbar roots can refer pain to the midthigh or even as far asthe anterior knee. Unless the patient’s pain can be repro-duced by passive rotation (hip joint), reproduced by torqueapplied to the thigh (femur bone), or reproduced by specificsigns in the back (radiculopathy), most patients with thispattern of pain need special radiographic procedures to de-termine the exact anatomic process.

EXAMINATION Because all significant diagnoses at thehip can affect the patient’s ambulation, the first priority inthe hip examination is to evaluate the patient’s gait, toler-ance of squatting, and general ability to move in the examroom. These simple screening tests allow rapid assessmentof the severity of the process. Next, assess the integrity ofthe hip joint by performing passive internal and external ro-tation, noting the patient’s tolerance of the maneuver and

any endpoint stiffness. If the range of motion is impairedand the endpoints cause severe pain, immediate evaluationfor AVN, occult fracture, acute synovitis, metastatic lesionof the femur, and so forth must be initiated. If the range ofmotion of the joint is normal, then the trochanteric and glu-teus medius bursae are palpated at the middle and superiorportions of the greater trochanter, respectively. Finally, be-cause the lumbar spinal nerves, SI joint, lateral femoral cu-taneous nerve, and lower abdominal vascular structures canrefer pain through the hip, the examiner concludes by per-forming the straight leg raise maneuver (lumbar radiculopa-thy), palpating the SI joint (SI joint strain or inflammation),assessing the sensation of the upper outer thigh (meralgiaparesthetica), and palpating the lower extremity pulses (aor-toiliac occlusive disease).

ONE-MINUTE SCREENING HIP EXAM:MANEUVERS ASSESSING OVERALL HIPFUNCTION

The next six maneuvers represent the minimal examinationof the patient presenting with hip symptoms. Function test-ing, range of motion measurement, and screening maneu-vers for bursitis and lumbar radiculopathy provide enoughinformation to triage to x-ray, order appropriate labs, sug-gest general treatment recommendations, or proceed tomore detailed examination and treatment.

Lateral hip pain Trochanteric bursitisGluteus medius bursitisMeralgia parestheticaSnapping hip

Anterior hip pain Osteoarthritis of the hip(groin) Inflammatory arthritis

Avascular necrosisSeptic arthritisIliopectineal bursitisDislocation of the hipProsthesis fracture or looseningOccult fracture of the hip

Posterior hip pain Ischiogluteal bursitisHamstring pull

Referred pain Lumbar radiculopathySI strainVascular occlusive diseaseInguinal hernia

DIFFERENTIAL DIAGNOSIS OF HIP PAINBASED ON ANATOMIC AREA

BOX 10-1

1. Observe the general function of the hip.a. Observe the patient’s normal gait with or without

heel and toe walking.b. Observe changing positions (sitting to standing,

squatting, climbing onto the exam table).2. Measure internal and external rotation of the joint

and note pain and endpoint stiffness.3. Palpate the trochanteric and gluteus medius bursae

for tenderness.4. Perform a straight leg raise maneuver and, if abnor-

mal, include a lower extremity neurologic exam.5. Palpate the SI joint 1 inch inferior and 1 inch medial

to the posterior superior iliac spine.6. Palpate the lower extremity pulses and, if abnormal,

measure capillary fill times for vascular insufficiency.

ESSENTIAL EXAMINATION OF THE HIPBOX 10-2

HIP 175

GAIT

SUMMARY: The ability to walk easily depends on a flexible hip joint, a strong iliopsoas muscle, astrong quadriceps muscle, and normal lumbosacralnerve roots.

MANEUVER: The patient is asked to walk in theexam room. Any significant gait abnormalities canbe enhanced by asking the patient to toe and heelwalk.

INTERPRETATION: Impairment of ambulation and inability to change position smoothly can be af-fected by severe hip arthritis, involvement of thebony femur (AVN or metastatic disease), dramaticloss of muscular support, or dramatic loss of lum-bosacral nerve function. In general, meralgia pares-thetica, mild hip arthritis, and most cases of bursitishave a minimal impact on ambulation.


SQUAT

SUMMARY: The ability to squat is influenced by thesupporting musculature, the hip joint, and the lubri-cating bursae over the trochanteric bursa.

MANEUVER: The patient is asked to squat as far as his or her pain level allows. Patients suspectedof having an advanced hip condition should be in-structed to perform the maneuver while holding onto the exam table.

INTERPRETATION: The squatting maneuver can beimpaired by moderate to advanced arthritis of thehip, moderate to severe bursitis, and any conditionreducing the effective strength of the supportingmuscles.

FIGURE 10–2. Observe the patient’s ability to squat.


CLIMB ONTO THE EXAM TABLE

SUMMARY: The ability to climb easily onto theexam table depends on a flexible hip joint, astrong iliopsoas muscle, a strong quadriceps muscle, and normal lumbosacral nerve roots.

MANEUVER: The patient is asked climb onto theexam table.

INTERPRETATION: Inability to change positionsmoothly can be affected by severe hip arthritis, involvement of the bony femur (AVN or metastaticdisease), dramatic loss of muscular support, or dramatic loss of lumbosacral nerve function. In gen-eral, patients with meralgia paresthetica, mild hiparthritis, and most types of bursitis have little diffi-culty performing this task.

FIGURE 10–3. Observe the patient’s ability to climb onto theexam table.

RANGE OF MOTION

SUMMARY: The hip joint is capable of moving in alldirections, a range of motion that is surpassed onlyby that of the glenohumeral joint of the shoulder. Aswith its companion ball-and-socket joint, early in-volvement of the joint is identifiable by loss of inter-nal and external rotation.

MANEUVER: The range of motion can be evaluatedwhile the patient is seated (depicted here) or recum-bent. Internal and external rotation are much morereproducible in the seated position because themovement of the buttocks is restricted. The patient isasked to keep the ischial tuberosities fixed on theexam table. Internal rotation is measured as the legswings out (normal 45 degrees), and external rota-tion is measured as the leg swings inward (normal45 degrees). Pain and endpoint stiffness are noted.

INTERPRETATION: Young women and patients withshallow acetabula may have 60–70 degrees of in-ternal and external rotation. Patients with osteoarthri-tis have a preferential loss of internal rotation. Thegreater the degree of arthritis, the greater the loss ofrotation (mild, 35–45 degrees; moderate, 15–30 de-grees; severe, less than 10 degrees of internal rota-tion). Avascular necrosis, occult hip fracture, metasta-tic bony lesions with fracture, and acute synovitiscause severe pain and severe loss of rotation.

FIGURE 10–4. Evaluate the range of motion of the hip joint.

HIP 177

TROCHANTERIC AND GLUTEUS MEDIUS BURSAE

SUMMARY: The trochanteric process is the mostprominent portion of the femur. The trochantericand gluteus medius bursae are located over themiddle and superior portion of the trochantericprocess, respectively. They lubricate and reducefriction between the gluteus medius tendon, thetensa fascia lata, the iliotibial band, and the under-lying periosteum of the bone.

MANEUVER: The trochanter can be palpated withthe patient in the sitting position or the lateral decu-bitus position. In either case, the hip must be flexedto 90 degrees for the examiner to adequately iden-tify the superior aspect of the trochanteric process.Firm pressure must be applied to determine localtenderness in the obese patient.

INTERPRETATION: Bursitis is the most common causeof local pain and tenderness over the trochantericprocess. However, tenderness is also seen with oc-cult fracture, stress fracture, and metastatic disease.

FIGURE 10–5. Palpate the trochanteric and gluteusmedius bursae.

STRAIGHT LEG RAISE

SUMMARY: The sciatic nerve arises from the lum-bosacral plexus, exits the pelvis through the sciaticnotch, and travels down the posterior aspect of theleg, forming the common peroneal and poplitealnerves. Straightening the leg while the hip is flexedat 90 degrees causes traction on the nerve.

MANEUVER: The maneuver can be performed in thesitting or lying position. The leg is gradually movedto the fully extended position. Ankle dorsiflexioncan be added in full extension to bring out the subtle case.

INTERPRETATION: A positive straight leg raise ma-neuver must reproduce the patient’s neuritic pain.The test is inconclusive if tightness or pain is feltonly in the hamstring area. Acute spinal root andspinal nerve irritation caused by herniated nucleuspulposus, trauma, compression fracture with frag-mentation, spondylolisthesis, epidural abscess, andepidural metastasis have a positive maneuver. Thetest usually is negative with lumbosacral osteoarthri-tis and spinal stenosis despite nerve compression.

FIGURE 10–6. Perform the straight leg raise maneuver.

ONE-MINUTE SCREENING EXAM:MANAGEMENT STRATEGIES

TRIAGE TO X-RAY For patients with a history oftrauma or risk of bony injury, those in whom hip arthritis orleg length discrepancy is suspected, or those with risk factorsare present for avascular necrosis:

• Order three views of the hip to assess injuries or directblows to the trochanteric process (fractures of the femoralhead, neck, intertrochanteric crest, and shaft) or to obtainbaseline films for possible occult fracture in the patientwith osteoporosis.

• Order a standing AP pelvis film for patients with a grad-ual loss of internal or external rotation (to assess os-teoarthritis of the hip joint or to obtain baseline films forpossible avascular necrosis).

• Order a standing AP pelvis for patients with tro-chanteric bursitis and a suspicion of a short leg (leglength discrepancy).

• Order a standing AP pelvis for patients with recurrent sub-luxation and ill-defined groin pain (shallow acetabulum).

TRIAGE TO THE LAB For patients with severe hip pain,impaired ambulation, or extremely guarded rotation, withor without fever:

• Order a complete blood cell count, uric acid, erythrocytesedimentation rate, and blood cultures (osteomyelitis, sep-tic arthritis, inflammatory arthritis, or pseudogout).

CONSIDER A BONE SCAN For patients with a historyof trauma, deep groin or ill-defined thigh pain, severe painwith internal or external rotation, or known history of can-cer (stress fracture, avascular necrosis, occult fracture of thefemur, or metastatic bony involvement is suspected).

CONSIDER MRI For patients with acute pain, im-paired gait, and impaired internal and external rotation(avascular necrosis, occult fracture of the femur, ormetastatic bony lesions).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate hip pain and stiffness, normalgait, and normal range of motion of the hip joint:

• Minimize weight-bearing activities (limit walking, stand-ing, and impact).

• Avoid physically demanding work, especially work that in-volves repetitious bending or twisting at the waist.

• Avoid direct pressure over the outer hip.• Sleep with a pillow between the legs.• Perform daily cross-leg, passive stretching exercises.• Apply ice over the affected area four times a day (if the pa-

tient is thin).• Recommend an anti-inflammatory medication for 10 to

14 days at full dosage.• Use crutches with touch-down weight bearing for 5 to

7 days (optional).• Use a Velcro lumbosacral back brace during the day

(optional).

DETAILED EXAMINATION: SPECIFIC HIPDIAGNOSES Perform a detailed examination of thehip for patients with persistent or chronic symptoms, mod-erate to severe hip pain and stiffness, antalgic gaits, moder-ate to severe trochanteric bursal tenderness, and acute lossof range of motion at the hip joint.

TROCHANTERIC BURSITIS Trochanteric bursitis, the mostcommon condition affecting the hip, is a common complication of lumbosacral spine stiffness, leg length discrepancy, knee arthritis,and ankle sprain. These diagnoses are characterized by gait im-pairment, which leads to an exaggerated movement and increasedfriction of the gluteus medius tendon and the tensor fascia lataover the trochanteric process of the femur. Treatment focuses on re-ducing inflammation and measures to restore or at least improvethe abnormal gait. If the condition is untreated, the normally paper-thin bursal wall thickens, undergoes fibrosis, and graduallyloses its ability to lubricate the outer hip.


HIP 179

PALPATE THE MIDPORTION OF THE GREATERTROCHANTERIC PROCESS

SUMMARY: The trochanteric process is the mostprominent portion of the femur. The trochantericbursa is located over the midportion of the processand lubricates and reduces friction between the glu-teus medius tendon, the tensa fascia lata, the iliotib-ial band, and the periosteum of the bone.

MANEUVER: The trochanter can be palpated withthe patient in the sitting position or the lateral decu-bitus position. In either case, the hip must be flexedto 90 degrees for the examiner to adequately iden-tify the superior aspect of the trochanter process.Firm pressure must be applied to determine the local tenderness in the obese patient.

ASSOCIATED SIGNS: The range of motion of thehip should be normal, with minimal endpoint stiff-ness. The back is examined for loss of flexibility(abnormal Schober test). The alignment of the pelvisis inspected for possible short leg. The ankle andknee are examined for conditions that could alterthe patient’s gait. Neuropathy, previous stroke, andother neurologic abnormalities that could contributeto an altered gait are sought.

INTERPRETATION: Bursitis is the most common causeof local trochanteric tenderness. However, tender-ness is also seen with occult fracture, stress fracture,and metastatic disease.

FIGURE 10–7. Palpate the midportion of the greatertrochanteric process for bursal tenderness.


SUMMARY: The trochanteric bursa is located be-tween the gluteus medius tendon and the femur. Its deepest portion is part of the periosteum of thefemur. A local anesthetic block is placed below the gluteus medius tendon and just above the periosteum of the trochanteric process.

POSITIONING: Lateral decubitus position, hip andknees flexed to 90 degrees.

SURFACE ANATOMY: Middle and superior portionsof the greater trochanter (crown).

POINT OF ENTRY: Mid-trochanter.


NEEDLE: 11⁄2 inch, 22 gauge or 22-gauge spinalneedle.


ANESTHESIA: Ethyl chloride, skin: 1 mL at the inter-face of the subcutaneous fat and tendon; 1 mL atthe periosteum.

FIGURE 10–8. Local anesthetic block of the mid-trochantericprocess to confirm trochanteric bursitis.

GLUTEUS MEDIUS BURSITIS The clinical presentation ofbursitis of the gluteus medius (the lubricating sac located atop thesuperior portion of the trochanteric process) is nearly identical tothat of trochanteric bursitis. Although gluteus medius bursitis ismuch less common, the gluteus medius bursa is just as important

as the trochanteric bursa in maintaining the smooth movement ofthe gluteus medius tendon and tensor fascia over the lateral femur.This condition differs from trochanteric bursitis in the location ofthe discomfort (“gluteal” area) and the location of the palpabletenderness (directly over the superior trochanter).

PALPATE THE SUPERIOR TROCHANTERICPROCESS

SUMMARY: The trochanteric process is the mostprominent portion of the femur. The gluteus mediusbursa is located over the superior portion of theprocess and lubricates and reduces friction betweenthe gluteus medius tendon, the tensa fascia lata, theiliotibial band, and the periosteum of the bone.

MANEUVER: The trochanter can be palpated withthe patient in the sitting position or the lateral decu-bitus position. In either case, the hip must be flexedto 90 degrees for the examiner to adequately iden-tify the superior aspect of the trochanter process.Firm pressure must be applied to determine localtenderness in the obese patient.

ASSOCIATED SIGNS: The range of motion of thehip should be normal, with minimal endpoint stiff-ness. The back is examined for loss of flexibility(abnormal Schober test). The alignment of the pelvisis inspected for possible short leg. The ankle andknee are examined for conditions that could alterthe patient’s gait. Neuropathy, previous stroke, andother neurologic abnormalities that could contributeto an altered gait are sought.

INTERPRETATION: Bursitis is the most common causeof local trochanteric tenderness. However, tender-ness is also seen with occult fracture, stress fracture,and metastatic disease.

FIGURE 10–9. Palpate the superior trochanteric processfor bursal tenderness.


HIP 181


SUMMARY: The gluteus medus bursa is located be-tween the gluteus medius tendon and the superioraspect of the trochanteric process of the femur. Its deepest portion is part of the periosteum of thefemur. A local anesthetic block is placed below the gluteus medius tendon and just above the periosteum of the trochanteric process.


SURFACE ANATOMY: Superior portion of thegreater trochanter (crown).

POINT OF ENTRY: Superior trochanter.

ANGLE OF ENTRY: 45-degree angle.



ANESTHESIA: Ethyl chloride, skin: 1 mL at the inter-face of the subcutaneous fat and tendon; 1 mL atthe periosteum.

FIGURE 10–10. Local anesthetic block to confirm gluteusmedius bursitis.

OSTEOARTHRITIS OF THE HIP Osteoarthritis is the secondmost common condition affecting the hip. It is characterized bydeep groin pain that often radiates down the anterior leg to theknee, pain that is aggravated by weight bearing and that limits theability to walk fixed distances, local tenderness 1 inch below the

inguinal ligament and deep to the femoral artery, impairment of internal rotation (best measured in the seated position), and lossof articular cartilage, demonstrated on weight-bearing films of thehip (a standing AP pelvis x-ray).


WEIGHT-BEARING AP PELVIS X-RAY

SUMMARY: A standing, weight-bearing AP pelvis x-ray is an excellent way to compare right and lefthip joints for osteoarthritic wear. The articular widthof the hip joints is measured between the superiorhead of the femur and the superior acetabulum.Because osteophyte and subchondral cyst formationvary from patient to patient, the degree of wear isbased strictly on the width of the articular cartilage.In general, the width correlates reasonably wellwith the degree of rotation impairment seen on examination.

MANEUVER: The x-ray is performed in the standingposition with the shoes off.

INTERPRETATION: The normal articular width is 4 to5 mm.

FIGURE 10–12. Weight-bearing AP pelvis x-ray to con-firm the presence of osteoarthritis of the hip.

MEASUREMENT OF INTERNAL AND EXTERNAL ROTATION

SUMMARY: Progressive osteoarthritis of the hip di-rectly and preferentially affects the rotation rangeof motion. Internal rotation is affected to a greaterdegree in most patients. Range of motion measure-ments can be more accurately reproduced if thepelvis is fixed in position (with the patient sittingwith the ischial tuberosities flat against the examtable) rather than while the patient is lying down.

MANEUVER: The patient is asked to keep the pelvisflat and not to roll the buttocks when rotation is ap-plied. With the leg in the dependent position (0 de-grees), internal and external rotation are measured,and the endpoint symptoms of pain and stiffnessare noted.

ADDITIONAL SIGNS: The patient cannot perform afull squat. The patient with advanced arthritis can-not reach his or her feet to remove shoes or socks.With ever greater impairment of rotation, reducedhip flexion and abduction are noted (the Patrickmaneuver [flexing, abducting, and externally rotat-ing the hip] causes groin pain). Groin tenderness is variable and is located 1 inch inferior to the mid-point of the inguinal ligament.

INTERPRETATION: The greater the degree of arthritis,the greater the loss of rotation (mild, 35–45 de-grees; moderate, 15–30 degrees; severe, less than10 degrees of internal rotation). Patients with os-teoarthritis have moderate pain and mild to moder-ate endpoint stiffness. By comparison, patients withavascular necrosis, occult hip fracture, metastaticbony lesions with fracture, and acute synovitis havesevere pain, severe endpoint pain, and severe limi-tation of rotation.

FIGURE 10–11. Measurement of internal and externalrotation to evaluate the severity of hip arthritis.

ACUTE ARTHRITIS OF THE HIP Acute arthritis is an uncom-mon condition affecting the hip. It is characterized by severe deep groinpain that often radiates down the anterior leg to the knee, intoleranceof weight bearing (patients often use a cane, walker, or crutches), dra-

matic local tenderness 1 inch below the inguinal ligament and deep to the femoral artery, severe pain with even 5 to 10 degrees of internalrotation and external rotation (best measured in the seated position),and inflammatory exudates, demonstrated on aspiration of the joint.

HIP 183

MEASUREMENT OF INTERNAL AND EXTERNALROTATION

SUMMARY: Acute synovitis from pseudogout, inflam-matory arthritis, or the rare case of septic arthritis(gonorrhea or Staphylococcus aureus) is character-ized by severe groin pain, severe intolerance ofweight bearing, and severe pain and loss of rangeof motion during internal and external rotation ofthe hip.

MANEUVER: All directions of motion are impairedand painful, especially in the case of septic arthritis.

ADDITIONAL SIGNS: Weight bearing is impairedwith acute synovitis and impossible with septicarthritis. The patient may assume a position in bedwith the hip partially flexed (relaxing the hip cap-sule). Groin tenderness varies from moderate to se-vere (1 inch inferior to the midpoint of the inguinalligament). The Patrick maneuver (flexing, abduct-ing, and externally rotating the hip) causes severegroin pain or is impossible to perform dependingon the acuteness of the process.

INTERPRETATION: The greater the degree of arthri-tis, the greater the loss of rotation (mild, 35–45 de-grees; moderate, 15–30 degrees; severe, less than10 degrees of internal rotation). Patients with os-teoarthritis have moderate pain and mild to moder-ate endpoint stiffness. By comparison, patients withavascular necrosis, occult hip fracture, metastaticbony lesions with fracture, and acute synovitis havesevere pain, severe endpoint pain, and severe lossof rotation.

FIGURE 10–13. Measurement of internal and externalrotation to assess the integrity of the hip joint.


ASPIRATION OF THE HIP JOINT

SUMMARY: Synovial fluid analysis is necessary todistinguish septic arthritis from the acute synovitiscaused by crystal deposition disease or inflamma-tory arthritis (rheumatoid arthritis). If fluid is not ob-tained from the lateral approach, consultation withan interventional radiologist or orthopedic surgeonis necessary.


SURFACE ANATOMY: Superior portion of thegreater trochanter (crown).

POINT OF ENTRY: 1 inch above the superiortrochanter.


NEEDLE: 31⁄2 inch, 22-gauge spinal needle.


ANESTHESIA: Ethyl chloride, skin: 1 mL to the periosteum.

FIGURE 10–14. Aspiration of the hip joint to obtain fluid toconfirm acute synovitis or septic arthritis.

HIP 185

MERALGIA PARESTHETICAThe lateral femoral cutaneous nerve, a pure sensory nerve, is sus-ceptible to compression as it courses from the lumbosacral nerveplexus, through the abdominal cavity, under the inguinal liga-ment, and into the subcutaneous tissue of the thigh. Symptoms

range from numbness and tingling (hypesthesia) to burning pain(paresthesia) over the upper outer thigh. Pain referred beyond theupper outer thigh or pain accompanied by impaired reflexes ormuscular weakness suggests either trochanteric bursitis or lumbarradiculopathy.

SENSATION OF THE ANTEROLATERAL THIGH

SUMMARY: The lateral femoral cutaneous nerve en-ters the upper thigh 1 inch medial to and approxi-mately 1 inch inferior to the anterior superior iliacspine and innervates the skin of the lateral and to a lesser extent the anterior mid- to upper thigh. It is most susceptible to compression in the inguinalarea but can be irritated by pathologic conditionsin the pelvis.

MANEUVER: The skin is tested for light touch, pin-prick, and deep pain sensation with a cotton ball,a sharp point, and pinching.

ADDITIONAL SIGNS: The range of motion of thehip is normal. Any pain or paresthesia extendingdown the leg should be ascribed to lumbar radicu-lopathy rather than the lateral femoral cutaneousnerve.

INTERPRETATION: Loss of sensation (hypesthesia) or a feeling of heightened sensation (dysesthesia or hyperesthesia) is characteristic of the condition.Because the nerve provides only sensation to theskin, changes in motor function suggest lumbarradiculopathy.

FIGURE 10–15. Assess the sensation of the anterolateralthigh for meralgia paresthetica.


SUMMARY: A local anesthetic block is placed overthe lateral femoral cutaneous nerve just above the fascial plane of the quadriceps to distinguishmeralgia paresthetica from referred pain from the lumbosacral roots.

POSITIONING: Supine.

SURFACE ANATOMY: Anterior superior iliac spine,inguinal ligament, and symphysis pubis.

POINT OF ENTRY: One inch medial and 1 inch inferior to the anterior superior iliac spine.



DEPTH: 1⁄2 to 11⁄2 inches to the subcutaneous fat–fascia interface.

ANESTHESIA: Ethyl chloride, skin: 1 mL at the inter-face of the subcutaneous fat and the fascia.

FIGURE 10–16. Local anesthetic block of the lateral femoralcutaneous nerve to confirm meralgia paresthetica.


AVASCULAR NECROSIS OF THE HIP Avascular necrosisof the hip (osteonecrosis) results from an impairment of the bloodsupply to the head of the femur. Risk factors for ischemia includetrauma, diabetes, alcoholism, iatrogenic Cushing’s disease, andhematologic states causing high viscosity. Patients presenting withsevere groin pain, an antalgic gait, and acute loss of internal and

external rotation must avoid all weight bearing while emergent ra-diographic studies are performed. Failure to make this diagnosis ina timely fashion places the patient at risk for the complications ofthe ischemic process: collapse of the femoral head, coxa plana, andpremature osteoarthritis.

RANGE OF MOTION TESTING

SUMMARY: Avascular necrosis is an acute processthat presents with dramatic changes on examina-tion of the hip. The pain typically is severe enoughto impair normal weight bearing. Patients oftenrefuse to walk and come in with crutches or in awheelchair.

MANEUVER: The patient is asked to keep the pelvisflat and not to roll the buttocks when rotation is ap-plied. With the leg in the dependent position (0 de-grees), internal and external rotation are measured,and the endpoint symptoms of pain and muscularguarding are noted. Most patients are unwilling toallow rotation beyond 30 degrees.

ASSOCIATED SIGNS: The Patrick maneuver ispoorly tolerated (flexion, abduction, and externalrotation, the figure-of-four position). The anvil testtypically is painful (fist percussion at the heel withthe leg held perfectly straight, transmitting the shockto the fracture site).

INTERPRETATION: Severe pain and limited rotationof the hip are seen with avascular necrosis, occultfracture of the hip, metastatic disease with fracture,and acute synovitis. Radiographic and laboratorytests are necessary to distinguish these conditionswith similar clinical presentations.

FIGURE 10–17. Range of motion testing in the evaluationof avascular necrosis.

PLAIN X-RAYS, BONE SCAN, OR MRI

SUMMARY: Plain x-rays of the hip may demonstratethe classic collapse of the femoral head, leading toa loss of the normal round configuration, the classicstep-off areas at the cortex, and the sclerotic bonewhere the proximal third impacts into the distal two-thirds of the femoral head. Comparative viewsof the right and left side can be obtained with astanding AP pelvis (if the patient can bear weight).Unfortunately, these changes occur days to weekslater, and therefore plain x-rays cannot be used asa screening test.

FIGURE 10–18. Plain x-rays, bone scan, or MRI to con-firm avascular necrosis.

HIP 187

OCCULT FRACTURE OF THE HIP Occult fracture of the hip,a nondisplaced fracture of the neck of the femur, is difficult to de-tect and should be suspected whenever the injured patient’s exami-nation demonstrates severe anterolateral hip tenderness, severepain with even partial weight bearing, and intolerance of passive

hip rotation. Routine x-rays of the hip and pelvis are notoriouslydifficult to interpret because of osteoporosis. If the diagnosis is suspected, the patient must avoid weight bearing (to avoid comple-tion of the fracture) until MRI or serial radiographs of the hiprules out this difficult diagnosis.

INTERNAL AND EXTERNAL ROTATION

OBJECTIVE: Patients with known osteoporosis are athigh risk for occult fracture of the hip. Older adultswho have fallen, are intolerant of weight bearing,and have significant loss of rotation should be eval-uated by special radiographic testing to exclude occult fracture.

MANEUVER: The examiner places one hand at theankle and one hand at the knee. The lower leg isrotated laterally to test internal rotation and medi-ally to test external rotation. The patient is in-structed to avoid rolling the buttocks during the ma-neuver. If the patient is unable to sit, the leg can berolled from side to side while lying (the log roll ma-neuver) to evaluate the tolerance of rotation.

ADDITIONAL SIGNS: Other than the anvil sign (fistpercussion of the heel with the leg in the straightposition, transmitting pressure through a potentialfracture site), there are no other specific signs ofbony involvement.

INTERPRETATION: Older adults with osteoporosisare a high risk for hip fracture. Initial plain films ofthe hip are notoriously inaccurate in detecting sub-tle cracks in the bone from trauma. It may take sev-eral weeks for osteoporotic bone to demonstrate afracture line in severely osteopenic bone. Bonescanning or MRI is the test of choice to rule out occult fracture of the hip.

FIGURE 10–19. Measure internal and external rotation toassess the integrity of the femur.

BONE SCAN OR MRI

CASE: This 75-year-old woman with osteoporosis fellout of bed and immediately developed hip pain.Bedside plain x-rays performed in the nursing homewere interpreted as normal, without fracture. Thepatient’s hip pain persisted. Turning in bed becameprogressively more painful. She refused to get up touse the bathroom. Examination disclosed severepain with any attempts to rotate the hip joint.

MANEUVER: Approximately 20 MCi technetium-99m is injected into the patient’s forearm. Fourhours after the injection of the isotope, bone flowand postperfusion radioactivity images arerecorded.

INTERPRETATION: Radioisotopic bone scanning is a more sensitive test for the identification of occultfractures than the initial screening plain films.FIGURE 10–20. Bone scan or MRI to evaluate occult fracture.


INTERNAL AND EXTERNAL ROTATION

SUMMARY: Patients with known metastatic diseaseof the prostate, breast, kidney, thyroid, or lung (thefive types known to metastasize frequently to bone)must be evaluated in a timely fashion wheneverpain in or around the hip develops. Thinning of thecortical bone thickness leads to an unacceptablerisk of bony fracture.

MANEUVER: The examiner places one hand at theankle and one hand at the knee. The lower leg is ro-tated laterally to test internal rotation and medially totest external rotation. The patient is instructed toavoid rolling the buttocks during the maneuver.

ADDITIONAL SIGNS: Other than the anvil sign (fistpercussion of the heel with the leg in the straightposition, transmitting pressure through a potentialfracture site), there are no other specific signs ofbony involvement.

INTERPRETATION: Early metastatic disease involvingthe femur may remain asymptomatic and unde-tectable for weeks. Periodic bone scanning maydemonstrate preclinical disease. Dramatic symptomsarise when the weakened femur microcracks andthen fractures. Any patient with early involvement ofthe femur on bone scan must have periodic plain x-rays to determine the integrity of the cortical bone.

FIGURE 10–21. Severe pain with internal and external ro-tation of the hip.

METASTATIC DISEASE AFFECTING THE FEMURMetastatic involvement of the femur must be diagnosed and treatedin a timely fashion in order to avoid the disastrous complication ofsecondary fracture. Patients with a history of malignancy, severe,deep thigh pain, and apprehension with weight bearing and an ex-amination demonstrating severe thigh tenderness, severe pain with

even partial weight bearing, and intolerance of passive rotation ofthe hip must undergo special studies to exclude bony involvement.Routine x-rays of the hip and pelvis are notoriously difficult to inter-pret. If the diagnosis is suspected, the patient must avoid weightbearing (to prevent completion of the fracture) until bone scanning,MRI, or serial x-rays rule out this elusive diagnosis.

ROUTINE X-RAYS OF THE FEMUR OR BONESCANNING

CASE: This 45-year-old woman had breast cancerdiagnosed a year earlier. Shortly thereafter, she de-veloped skeletal pain in a wide number of areas in-cluding her hips. Plain x-rays disclosed erosion ofthe cortical bone on the right side. Prophylactic rod-ding of the femur was performed.

MANEUVER: Approximately 20 MCi technetium-99m is injected into the patient’s forearm. Fourhours after the injection of the isotope, bone flowand postperfusion radioactivity images arerecorded.

INTERPRETATION: Radioisotopic bone scanning is amore sensitive test for the identification of stressfractures, occult fractures, osteoblastic tumors, andinfected bone.

FIGURE 10–22. Routine x-rays of the femur or bonescanning to look for primary or secondary bony involvement ofthe femur.

HIP 189

HIP PAIN CAUSED BY AORTOILIAC VASCULAROCCLUSIVE DISEASE Claudication caused by aortoiliac oc-clusive disease at or just distal to the bifurcation of the aorta(Leriche’s syndrome) can mimic intrinsic disease at the hip (glu-teus or upper thigh pain that is aggravated by walking). This di-

agnosis should be considered whenever significant risk factors foratherosclerosis are present, the vascular examination of the lowerextremities is impaired, and the hip joint and soft tissues are nor-mal on examination.

LOWER EXTREMITY PULSES

SUMMARY: The aorta branches to form the iliac arteries, which in turn branch to form the femoralarteries.

MANEUVER: The dorsalis pedis (dorsum) and theposterior tibialis (medial ankle) arteries are pal-pated, and the capillary fill times of the toes arecompared with those of the fingers.

ADDITIONAL SIGNS: Poor perfusion of the foot canchange coloration. Loss of hair over the dorsum of the foot or up the pretibial surface is common.Severely restricted blood flow can cause ulcerationof the skin and chronic osteomyelitis.

INTERPRETATION: Atherosclerotic disease affectingthe bifurcation of the aorta (Leriche’s syndrome) or the iliac arteries can cause exercise-inducedpain in the buttock or upper thigh.FIGURE 10–23. Palpate the lower extremity pulses and

check capillary fill times.

DOPPLER ULTRASOUND OR ANGIOGRAPHY

SUMMARY: Atherosclerotic narrowing of the aortaor iliac arteries cause upper thigh or buttock claudication. Leriche’s syndrome (obstruction of the bifurcation of the aorta) causes bilateral buttockclaudication and impotence (insufficiency of the pudendal artery). Vascular insufficiency can be doc-umented by poor capillary fill in the feet, decreasedpulses, and abnormal flow by Doppler ultrasound.Radiographic angiography is necessary to confirmthe exact anatomic area of obstruction.

FIGURE 10–24. Doppler ultrasound or angiography toconfirm vascular insufficiency.


HIP PAIN REFERRED FROM THE LUMBOSACRALSPINE OR SI JOINT The back and SI joints commonly referpain to or through the hip. The lower lumbar roots refer painthrough the gluteus and posterolateral thigh areas. The SI joints re-fer pain into the gluteal area. Referred pain from the lumbosacral

spine or the SI joint should be considered whenever back symptomsaccompany the pain, the pain extends past the knee, paresthesia orhypesthesia accompanies the pain, and the examination of the hipjoint and soft tissues is unremarkable.

SI JOINT

SUMMARY: The SI joint is located 1 inch medialand 1 inch inferior to the posterior superior iliacspine. In order to reproduce the patient’s pain,pressure is applied over the joint and directed in adownward and slightly outward direction (the iliumlies directly over the joint).

MANEUVER: The patient is placed in the prone po-sition. Local tenderness over the SI joint is com-pared with the adjacent bones (sacrum and iliaccrest) and the origin of the erector spinae muscle.

ADDITIONAL SIGNS: The Patrick maneuver, alsocalled the Faber maneuver (flexion, abduction, andexternal rotation of the hip), can reproduce thepain of moderate to severe SI strain and sacroiliitis.Compression of the pelvis against the exam tablewith the patient in the lateral decubitus position isoccasionally positive.

INTERPRETATION: Local tenderness is mild to moder-ate with SI strain, the most common condition af-fecting the joint. Moderate to severe tenderness ischaracteristic of sacroiliitis seen with the inflamma-tory spondyloarthropathies (e.g., Reiter’s disease,ankylosing spondylitis).

FIGURE 10–25. Palpate the SI joint.


SUMMARY: When paraspinal muscle spasm orradiculopathy coexists with focal findings at the SIjoint, local anesthetic block is used to confirm theexact source of the patient’s pain.

TECHNIQUE: Enter 1 inch caudal to the posteriorsuperior iliac spine and 1 inch lateral to the mid-line; advance at a 70-degree angle to the firm resistance of the posterior supporting ligaments.

POSITIONING: Lying prone, completely flat.

SURFACE ANATOMY: Spinous processes, theparaspinal muscles, and the iliac crests.

NEEDLE: 11⁄2 inch or 31⁄2 inch, 22 gauge.


VOLUME: 1 to 2 mL local anesthetic, 1 mL K40, orboth.

NOTE: The injection should be placed flush againstthe periosteum at the junction of the sacrum and theileum. If the SI joint is responsible for the patient’spain, the general function and pain should improveafter local anesthetic is placed over the joint.

FIGURE 10–26. Local anesthetic block to confirm the involvement of the SI joint.

HIP 191

LOWER EXTREMITY NEUROLOGIC EXAM

SUMMARY: The patient describes a lancinating painthrough the hip that extends down the leg, throughthe knee, and into the foot. The examination of thehip is unremarkable (normal mobility, 45 degreesof internal and external rotation, and no localizedtenderness).

MANEUVER: A full neurologic examination of thelower extremities is necessary. The straight leg raisemaneuver is performed on the right and left sides.Sensory testing of the feet for light touch, pinprick,and deep pain sensation is combined with reflextesting and motor testing of dorsiflexion and plantarflexion.

ANATOMY: The nerves of the lumbosacral plexusprovide sensation and motor function to the lowerextremities. The 5th lumbar root (L4–L5 disk) is responsible for sensation over the top of the footand dorsiflexion. The S1 root (L5–S1 disk) is responsible for sensation on the bottom of the foot and plantarflexion.

INTERPRETATION: Impairment of the L5 or S1 rootcan cause pain through the buttock, into the leg(lateral thigh [L5] or posterior thigh [S1]), anddown the leg to the foot. The L5 dermatome extends to the dorsum of the foot and the S1 dermatome on the plantar surface.

FIGURE 10–27. Perform a lower extremity neurologicexam.

CT SCANNING OF THE LUMBAR SPINE

SUMMARY: If an intrinsic condition of the hip is un-likely and the patient describes a posterior hip painthat radiates down the leg beyond the knee, thelumbosacral spine is scanned for possible nerveroot compression. In addition, CT scanning of thelumbar spine is necessary to identify the underlyingcause of recurrent or chronic hip bursitis. Morethan 60% of patients with hip bursitis have signifi-cant disorders in the lumbosacral spine. These include spinal stenosis, subclinical disk disease,chronic lumbosacral muscle spasm from osteo-arthritis, scoliosis, or spondylolisthesis.

ANATOMY: The spinal column is formed by the ver-tebral bodies and vertebral disks anteriorly, the lat-eral recesses and facet joints laterally, and the pos-terior elements. In this case, a large disk herniation(arrows) is compressing the right S1 nerve rootagainst the facet joint.

INTERPRETATION: In the evaluation of lumbarradiculopathy, the neuroanatomic abnormalitiesseen on CT scan must be correlated directly withthe neurologic findings on examination of the lowerextremities.

FIGURE 10–28. CT scanning of the lumbar spine to deter-mine the cause of lumbar radiculopathy.



Tender mid-trochanter #1: Trochanteric bursitis Local anesthetic block of the at the mid-trochanteric process

Associations: stiff back, short leg, ankle or knee disorders, stroke

Normal range of motion of the hip with minimal endpoint stiffness

Tender superior trochanter #2: Gluteus medius bursitis Local anesthetic block at the superior trochanteric process

Associations: stiff back, short leg, ankle or knee disorders, stroke

Normal range of motion of the hip with mild endpoint stiffness

Stiffness and mild pain with internal or external Osteoarthritis of the hip Standing AP pelvis x-rayrotation

Tenderness over the anterior hip

Abnormal Patrick maneuver

Hypesthesia or paresthesia over the anterolateral Meralgia paresthetica Examinationthigh

No evidence of lumbar radiculopathy

No evidence of hip disease

Acute loss and severe pain with internal Avascular necrosis of the MRI, AP pelvis x-ray, or aspiration of the hip by fluoroscopyor external rotation hip, acute arthritis,

septic arthritis

Limping with an antalgic gait



Acute loss and severe pain with internal or Occult fracture of the hip MRI, AP pelvis x-rayexternal rotation after an injury

Severe antalgic gait or refusal to bear weight



Diminished dorsalis pedis and posterior tibial pulses Vascular insufficiency Doppler study, angiogram

Delayed capillary fill times

� Straight leg raise maneuver reproducing Lumbar radiculopathy CT or MRI demonstrating nerve compression (necessary ifthe radicular pain motor signs are present)

Schober test: 20–40% of normal spinal flexion


Abnormal lower extremity neurologic exam

Pain aggravated by torque applied to the femur Primary or secondary Full x-ray of the femur, bone scaninvolvement of the femur

Localized bony tenderness

� Anvil sign


HIP 193

COMMON HIP FRACTURES

PELVIS FRACTURE

SUMMARY: The successful management of a frac-tured pelvis requires the combined clinical skills ofthe primary care provider, the orthopedic surgeon,and the urologist. Blunt trauma severe enough tofracture the sacrum, ilium, ischium, or pubic bonesoften leads to injury of the underlying organ sys-tems. Life-threatening hemorrhage; injury to thebladder, urethra, or ureters; or gastrointestinal in-jury to the colon must be assessed quickly for possi-ble emergent treatment.

After the patient has been stabilized medically, spe-cific x-rays should be obtained to determine theseverity and classification of the injury. The x-raysshould include cervical spine, chest, posteroanteriorpelvis, and inlet and outlet views of the pelvic ring.If the acetabulum is involved, special iliac and obtu-rator views or a CT scan of the entire pelvis must beobtained. With these x-rays, the fractures can beclassified according to the degree of pelvic ring dis-ruption, the involvement of the acetabulum, and thedegree of displacement and instability of the bonyfragments in the vertical and rotational directions.

Hospitalization, sling traction, and close observationfor the first 24 to 48 hours, including hemodynamicmonitoring, are combined with early pin placementfor external fixation or open reduction and internalfixation. Unstable patients with ongoing retroperi-toneal hemorrhage should be evaluated by pelvicangiography and treated with embolization.

FIGURE 10–29. Pelvis fracture.

DISLOCATION OF THE HIP

SUMMARY: Dislocation of the hip is an uncommonproblem. Immediate surgical referral is necessary.The prognosis for complete recovery is guarded.Recurrent dislocation, avascular necrosis of thefemoral head, sciatica from direct compression,and late-onset osteoarthritic wear are the most com-mon complications. The patient must be reexaminedfrequently, with serial examinations and radio-graphs monitoring for avascular necrosis in thedays and weeks after reduction.

FIGURE 10–3O. Dislocation of the hip.


HIP FRACTURE

SUMMARY: Fractures of the femur are divided intofractures involving the hip joint and fractures of the femur. Hip fractures are further subdivided intoimpacted, occult, avascular necrosis, stress, andnondisplaced and displaced neck fractures.Fractures of the femur are further subdivided into intertrochanteric, trochanteric process, sub-trochanteric, shaft, and supracondylar fractures (although the latter traditionally is grouped withfractures of the knee). All of these fractures aretreated surgically (internal fixation, hemiarthro-plasty, or total hip replacement), with the exceptionof certain impacted and occult fractures, stress frac-tures of the femoral neck, and avascular necrosis.The primary care physician must be able to diag-nose and initiate the early treatment of these fourfractures.

EMERGENCY DEPARTMENT TREATMENT FOR HIPFRACTURE: The patient presents with a displacedfemoral neck fracture with a foreshortened leg thatis externally rotated. The extremity must be sup-ported carefully during transfers. The patient mustbe evaluated for a cardiovascular event that couldhave caused the fall. Appropriate intravenous anal-gesia should be provided. Traction should be ap-plied at 5 to 10 pounds, depending on the size of the patient and the bulk of the quadriceps.Consultation with an orthopedic surgeon should bemade emergently.

FIGURE 10–31. Hip fracture and fractures of the femur.

• Progressive involvement of the hip joint is characterizedby a loss of internal rotation followed by loss of exter-nal rotation. The severity and progression of os-teoarthritis of the hip can be estimated by the loss of in-ternal rotation.

• Avascular necrosis of the hip, occult fracture of the hip,metastatic disease affecting the femur with fracture, andacute synovitis of the hip are all characterized by severepain and limitations of internal and external rotation.

• The classic position of comfort with acute swelling ofthe hip joint (hemorrhage, acute synovitis, or septicarthritis) is with the leg partially flexed to 45 degrees.This relaxes the tension of the distended capsule.

• Patients who describe pain through the gluteal area butlimited to the upper thigh have either gluteus mediusbursitis or referred pain from the SI joint.

• Meralgia paresthetica is inflammation of the lateralfemoral cutaneous nerve, a pure sensory nerve. Any ac-companying symptoms extending past the knee or in-volving the motor function of the lower extremity arisefrom the lumbar roots (lumbar radiculopathy).

CLINICAL PEARLS

• Severe episodes of trochanteric bursitis can refer paindown the leg to the knee (following the course of thefemur and the accompanying iliotibial band). Pain thatrefers from the hip and extends beyond the knee to thefoot is much more likely to be caused by lumbarradiculopathy.

• Trochanteric and gluteus medius bursitis rarely coexistwith osteoarthritis of the hip. A loss of movement fromhip arthritis nearly precludes the development of hipbursitis.

• Persistent trochanteric or gluteus medius bursitis cancause enough of a gait disturbance to cause contralateralhip bursitis. Chronic bursitis (either trochanteric or glu-teus medius bursitis) is the main common cause of il-iopectineal bursitis.

• Ten percent of trochanteric and gluteus medius bursitisis caused by the gait disturbance caused by leg lengthdiscrepancy.

• If trochanteric or gluteus medius bursitis is diagnosed,then next immediate step is to identify the cause of theunderlying gait disturbance (stiff back, SI strain, short leg,knee or ankle disorder, or chronic neurologic disease).

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CHAPTER 11: KNEE


Diagnoses

Patella (most common)Subluxation or dislocationPatellofemoral syndromeDashboard knee (chondral fracture)Patellofemoral osteoarthritisPatella alta

Main jointOsteoarthritis: medial compartment or lateral

compartmentInflammatory arthritisSeptic arthritisHemarthrosis

BursaPrepatellar (“housemaid’s knee”)

Anserine bursitisBaker’s cystInfrapatellar (superficial or deep)

LigamentsMedial collateral injury: 1st, 2nd, 3rd degreeLateral collateral injury: 1st, 2nd, 3rd degreeAnterior cruciate injuryPosterior cruciate injury

Meniscal tearTraumatic or degenerative

Iliotibial band syndromeSnapping knee

Referred painTrochanteric bursitisHip jointFemurLumbosacral spine radiculopathy

Confirmations

Examination; x-ray: sunrise viewsExamination; x-ray: sunrise viewsArthroscopy (optional)X-ray: sunrise viewX-ray: lateral view of the knee

X-ray: bilateral standing anteroposterior knees

Aspiration and synovial fluid analysisAspiration, synovial fluid analysis, and cultureAspiration, synovial fluid analysis, and hematocrit

Aspiration, bursal fluid analysis, crystal analysis, and culture

Local anesthetic blockAspiration or ultrasoundLocal anesthetic block

Exam, local anesthetic blockExam, local anesthetic blockExam, magnetic resonance imaging (MRI)Exam, MRI

MRI, arthroscopy

Exam, local anesthetic blockExam

Exam, local anesthetic blockX-ray: standing anteroposterior pelvisBone scanComputed tomography (CT) scan, MRI,

electromyography

INTRODUCTION The knee’s unique anatomy consistsof three separate joint compartments (medial, lateral, andpatellar), the body’s largest and strongest muscles (quadri-ceps and hamstrings), four main ligaments (medial collat-eral ligament [MCL], lateral collateral ligament [LCL], an-terior cruciate ligament [ACL], and posterior cruciateligament [PCL]), five major bursal sacs, and the body’slargest synovial cavity. Because of this level of complexity,the knee has the greatest range of conditions, including avariety of injuries, the most susceptibility to age-relatedwear, and the most common episodes of inflammatoryarthritis and septic arthritis, a variety of conditions that isunmatched by any other joint in the body. In order to man-age this diverse group of conditions, physicians categorizepatients presenting with knee pain by degree of trauma,age, pain location, and the presence of effusion and in-flammatory change.

The differential diagnosis of knee pain varies with age.The active stage of Osgood–Schlatter epiphysitis occurs ex-clusively in teenagers. Athletic patients under age 40 aremore likely to develop patellofemoral syndrome, patellartendonitis (“jumper’s knee”), iliotibial band syndrome(mostly affecting runners), prepatellar and infrapatellar bur-sitis, and the ligament and cartilage injuries seen with mildto moderate trauma. With advancing age and decreasing ac-tivity, osteoarthritis and its consequences (effusion, anser-ine bursitis, secondary MCL strain, and degenerativemeniscal tear) and inflammatory arthritis dominate the dif-ferential diagnosis.

Knee pain location is very helpful in narrowing the differ-ential diagnosis. Medial knee pain is the most common pat-tern and is associated with medial compartment osteoarthri-tis, anserine bursitis, MCL strain, medial meniscal tears, andlarge knee effusions. Anterior knee pain is typical ofpatellofemoral syndrome (especially when bilateral), knee ef-fusion, prepatellar and infrapatellar bursitis, patellar ten-donitis, and Osgood–Schlatter disease. Posterior orpopliteal pain typically reflects the pressure of an acute ef-fusion or the compressive effects of a Baker cyst. Lateralknee pain, the least common pattern, is seen with iliotibialband syndrome, the much less common isolated lateral com-partment osteoarthritis, LCL strain, and lateral meniscal tear.

Knee effusion and prepatellar bursitis are the two condi-tions characterized by significant swelling and inflamma-tory change. Patients with acute knee effusion complain ofanterior or popliteal pain and an inability to fully flex theknee. By contrast, patients with prepatellar bursitis describeanterior pain and minimal impairment of knee flexion; mo-bility is preserved because the swelling is extra-articular.Because both conditions can be caused by trauma, acute in-flammation, or infection, aspiration and laboratory analysisare necessary to determine the exact cause.

Trauma plays an important role in the origin of many ofthe conditions affecting the knee.

Minor trauma is a contributing factor in flareups of os-teoarthritis, traumatic prepatellar bursitis, dashboard knee,and MCL strain. Injury plays an even greater role inhemarthrosis.

The dramatic injuries that lead to hemarthrosis includetears of the cruciates and collateral ligaments, meniscal car-tilage tears, disruption of the synovial capsule, and tibialplateau fractures. Major trauma (direct blows, falls onto the

anterior knee, and severe torque injuries) cause patellar, tib-ial, and distal femur fractures.

Finally, pain can be referred to the knee from the lowerlumbar nerve roots, from the hip, or from the femur.Lumbar level L4–L5 and lumbar level L5–S1 cause pain andnumbness over the outer knee and popliteal areas, respec-tively. Moderate to severe trochanteric bursitis commonlyrefers pain to the lateral knee. Occasionally pain is referredto the lower femur and anterior knee from conditions af-fecting the hip joint. Rarely, primary and secondary lesionsof the femur manifest pain at the knee. A referred pattern ofpain should always be considered when local signs of kneeswelling, tenderness, and impaired motion are absent.

SYMPTOMS In order to arrive at a specific diagnosis,the physician divides the patient’s knee symptoms into thefollowing three categories: symptoms that reflect the changein overall function, including loss of muscular support(weakness, giving out, collapsing), loss of smooth move-ment (catching, “something is wrong inside”), and difficultywith ambulation (limping, fatigue, favoring); symptoms thatsuggest the presence of a joint effusion, including descrip-tions of swelling and impaired bending (e.g., “I can’t squat,”“My knee doesn’t flex”), and popliteal tightness or fullness;and anatomically related symptoms such as pain location,inflammatory change, and abnormal noise (clicking, pop-ping, and grinding). The first two categories of symptomsare helpful in determining the severity of the condition.Larger joint effusions, impaired ambulation, and muscularweakness correlate directly with the severity of the process.

The most commonly described pattern of pain is alongthe medial aspect of the knee. Medial knee pain is the clas-sic pain described by patients with medial compartment os-teoarthritis, anserine bursitis (the most common inflamedbursa), MCL strain (the most common injured ligament),and medial meniscal tear (the meniscus with the greatestvulnerability to injury). Medial joint line pain is character-istic of osteoarthritis, second- and third-degree MCL in-juries, medial meniscal tears, and fractures of the tibialplateau. Medial tibial plateau pain, localized 1 to 11⁄2 inchbelow the joint line, is characteristic of anserine bursitis andmild MCL injuries.

A wide variety of conditions present with anterior kneepain, the second most common location of knee pain. Thisis the classic area of pain associated with injury to thequadriceps mechanism (the quadriceps muscle, its tendons,the patella, and the insertion of the patellar tendon on thetibial tubercle) and large knee effusions. Bilateral anteriorknee pain is characteristic of patellofemoral syndrome, par-ticularly in patients under age 45, and also of advanced os-teoarthritis involving all three compartments of the knee.Anterior knee pain accompanied by swelling and inflam-matory change is the characteristic presentation of acuteprepatellar bursitis. Focal anterior knee pain at the inferiorpole of the patella, the origin of the patellar tendon, is char-acteristic of patellar tendonitis, or jumper’s knee. As thename implies, this diagnosis is seen almost exclusively inathletes. Focal anterior knee pain at the tibial tubercle, theinsertion of the patellar tendon, is characteristic ofOsgood–Schlatter disease. This epiphysitis is seen exclu-sively in young men and woman under age 19 whose


growth centers are still active. Diffuse anterior knee painaccompanied by swelling and inflammatory change is seenwith inflammatory arthritis (e.g., rheumatoid arthritis, gon-orrhea, gout, pseudogout) or septic arthritis. Although itssymptoms are similar to those of acute prepatellar bursitis,patients presenting with acute inflammatory arthritis havedramatically impaired flexion.

Lateral knee pain is the least common pain pattern.Lateral compartment osteoarthritis, injuries to the LCL, andlateral meniscal tears are much less common than their me-dial counterparts. Lateral knee pain located at the jointline suggests lateral compartment osteoarthritis, injury ortear of the LCL, or a lateral meniscal tear. Focal lateral kneepain at the femoral condyle is the characteristic site of in-flammation of the iliotibial band syndrome. This diagnosisis practically certain when the pain is accompanied by pal-pable or even audible snapping.

Popliteal pain or pressure can accompany any of theaforementioned pain patterns. It is most commonly causedby the buildup of pressure caused by a large, acute effusion.When the patient flexes the effused knee, the quadricepsmechanism forces the fluid posteriorly. Pressure is exerted onthe gastrocnemius muscles, vascular structures, and branches

of the sciatic nerve, leading to local pain, lower extremityedema, and even sciatica, respectively. If the effusion persists,over time this hydraulic pressure leads to the formation of aBaker cyst, a natural extension of the chronic knee effusion.

Patients often describe a variety of noises arising at theknee, including crepitation, clicking, grinding, popping, andsnapping sounds. These often accompany osteoarthritis andpatellofemoral syndrome but also accompany meniscaltears and the iliotibial band syndrome. These are nonspe-cific with the exception of the snapping sound along the lat-eral femoral condyle that is characteristic of the iliotibialband syndrome.

EXAMINATION The examiner assesses the generalfunction of the knee by observing the patient’s gait and theability to squat, duck waddle, and change positions in theexam room. In addition, the examiner assesses muscularsupport by estimating the strength of the quadriceps muscleeither by lifting the unweighted leg off the exam table or ac-tively resisting leg extension.

To assess patellofemoral syndrome, the most commoncondition under age 45, the examiner vigorously com-presses the patella firmly against the femur, attempting torecreate the patient’s retropatellar pain and determinewhether the crepitation or clicking arises from the patello-femoral articulation. Knee effusion is suggested by generalfullness anteriorly, loss of the peripatellar dimples, tightnesswith passive flexion, and an abnormal heel-to-buttock dis-tance. Osteoarthritis of the knee is suggested by joint linetenderness and crepitation but must be confirmed withweight-bearing radiographs. Anserine bursitis, often accom-panying larger knee effusions, has a unique quarter-sizedarea of tenderness in the midline of the medial tibialplateau. The stability of the knee is assessed by varus andvalgus stress testing and by the anterior and posterior drawersigns. Meniscal tear and other conditions causing internal

KNEE 197

Anterior knee pain Patellofemoral syndromePatellar dislocationDashboard kneePatellofemoral osteoarthritisPatella altaKnee effusionPrepatellar bursitisOsgood–Schlatter syndromeInfrapatellar bursitisJumper’s kneeHemarthrosisCruciate ligament injuries

Medial knee pain Osteoarthritis of the medial compartment

Inflammatory arthritisSeptic arthritisAnserine bursitisMedial collateral ligament

injuryMedial meniscal tearTibial plateau fracture

Posterior knee pain Knee effusionBaker’s cyst

Lateral knee pain Lateral compartment osteoarthritis

Lateral collateral ligament injuryIliotibial band syndromeLateral meniscal tear

Referred pain Lumbar radiculopathyTrochanteric bursitisFemur boneHip bone

DIFFERENTIAL DIAGNOSIS OF KNEE PAINBASED ON ANATOMIC AREA

BOX 11-1

1. Observe the general function of the knee and lowerextremities.a. Observe the patient’s gait, ability to squat, and

ability to duck waddle.b. Observe the difficulties in changing position,

especially climbing onto the exam table.c. Estimate the strength and tone of the quadriceps

muscle.2. Perform patellar compression and assess the tracking

of the patellofemoral joint.3. Check for signs of effusion, such as general fullness,

loss of flexion, and abnormal heel-to-buttock distance.4. Palpate medial and lateral joint line tenderness.5. Palpate anserine bursa tenderness at the medial tibial

plateau.6. Perform varus and valgus stress testing and the ante-

rior and posterior drawer signs.7. Assess for joint line popping and loss of smooth

motion.

ESSENTIAL EXAMINATION OF THE KNEEBOX 11-2

derangement (uncommon in the nontraumatized knee) aresuggested by a history of loss of smooth function, locking inthe advanced case, and an examination showing focal jointline tenderness, popping, or simply a vague indefinablesense of something not being quite right with passivemovement of the joint.

Finally, the back, sacroiliac joint, and the hip commonlyrefer pain to the knee. The S1 root and sacroiliac joint referpain down the back of the leg to the popliteal space. The L5root, the trochanteric bursa, and the femur refer pain downthe outer thigh to the lateral area of knee. The hip joint andthe femur refer pain down the front of the thigh to the an-terior knee.

ONE-MINUTE SCREENING KNEE EXAM:MANEUVERS ASSESSING OVERALL KNEEFUNCTION

The next nine maneuvers represent the minimal examina-tion of the patient presenting with knee symptoms.Functional testing, measurement of knee flexion for thepresence of an effusion, and screening maneuvers forpatellofemoral syndrome, prepatellar bursitis, osteoarthritis,and anserine bursitis provide enough information to triageto x-ray, order appropriate labs, suggest general treatmentrecommendations, or proceed to more detailed examinationand treatment.


GAIT

SUMMARY: The ability to walk easily depends on a flexible knee joint, intact supporting ligaments, astrong quadriceps muscle, and normal lumbosacralnerve roots.

MANEUVER: The patient is asked walk in the examroom. Symptoms can be enhanced by asking thepatient to toe and heel walk.

INTERPRETATION: This maneuver is used as ascreening for the more severe conditions (acute ef-fusion, acute flare of osteoarthritis, acute inflamma-tory arthritis, and septic arthritis).


SQUAT

SUMMARY: The ability to squat is influenced by thesupporting musculature and ligaments, the kneejoint, and the prepatellar bursa.

MANEUVER: The patient is asked to squat as far ashis or her pain level allows, either standing freelyor holding on to the exam table.

INTERPRETATION: The ability to squat can be im-paired by any cause of an effusion, moderate toadvanced arthritis of the knee, insufficiency or in-jury to the supporting ligaments, and any conditionreducing the effective strength of the supportingquadriceps mechanism.

FIGURE 11–2. Observe the patient’s ability to squat.

KNEE 199

ABILITY TO DUCK WADDLE

SUMMARY: The ability to duck waddle depends ona well-supported knee free of significant meniscaldisorders, effusion, or arthritis and with intact collat-eral and cruciate ligaments.

MANEUVER: The patient is asked to squat and then move forward, transferring the weight backand forth from the right side to the left.

INTERPRETATION: The ability to duck waddle rulesout significant ligamentous instability, joint effusion,and significant damage to the meniscal cartilage.

FIGURE 11–3. Observe the patient’s ability to duck waddle.

STRENGTH OF THE QUADRICEPS

SUMMARY: Active leg extension depends on an in-tact patellar tendon, patella, and quadriceps ten-don and a reasonably toned quadriceps muscle.Resisting leg extension isometrically estimates thestrength of the quadriceps muscle.

MANEUVER: The patient is asked to extend the leg against the resistance placed at the lower leg.

INTERPRETATION: Inability to extend the leg is seenwith quadriceps tendon rupture, advanced os-teoarthritis of the knee, and anterior loose bodies.Weakness of the quadriceps muscle is seen withany chronic knee condition.

FIGURE 11–4. Estimate the strength of the quadriceps byresisting leg extension.

HEEL-TO-BUTTOCK MEASUREMENT

SUMMARY: The heel-to-buttock distance is used to assess the patient’s ability to flex the knee. Thismaneuver is an objective, easy to perform, and reproducible way to estimate knee flexion.

MANEUVER: The knee is passively flexed. The pa-tient’s tolerance of the maneuver is noted. The dis-tance between the posterior heel and the buttocks is measured.

INTERPRETATION: Knee flexibility may be reducedby bulky musculature and tightness or contractureof the quadriceps. Intrinsic knee conditions that im-pair flexion include effusion of the knee, a Bakercyst, large bony osteophytes, tight collateral liga-ments, and previous knee surgery (total knee re-placement, ACL repair).FIGURE 11–5. Perform the heel-to-buttock measurement to

assess knee effusion.


JOINT LINES

SUMMARY: The joint lines are formed by thefemoral condyles and the tibial plateaus. The menis-cal cartilage is located in the space between thetwo bones, and these are covered by the synovialmembrane and the collateral ligaments.

MANEUVER: With the leg fully extended, the supe-rior and inferior poles of the patella are identifiedand marked. The joint lines are located at the levelof the inferior pole of the patella in the midplane.

INTERPRETATION: Tenderness at the joint line ismost commonly caused by irritation of the synovialmembrane (e.g., osteoarthritis, inflammatory arthri-tis). However, meniscal and collateral ligament injuries cause tenderness at the same location.

FIGURE 11–7. Palpate the joint lines to assess the medial andlateral compartments of the knee.

PATELLAR COMPRESSION

SUMMARY: The patella is the largest sesamoid boneof the body, centered over the distal femoralgroove and embedded in the large tendon of thequadriceps muscle.

MANEUVER: The patella is grasped firmly andmoved back and forth and up and down in thegroove of the femur. Retropatellar pain and crepita-tion are noted.

INTERPRETATION: Focal chondromalacia begins inthe inferior aspect of the femur. To identify the earlypresentation of this condition, emphasis is placedon compression of the patella in the inferior aspectof the femoral groove. As the condition progresses,pain and crepitation can be demonstrated over theentire groove.

FIGURE 11–6. Perform patellar compression to assesspatellofemoral syndrome.

KNEE 201

INSPECT THE PREPATELLAR BURSA

SUMMARY: The bursa is one of four synovial linedstructures that lubricate the quadriceps mechanism.The other three are the suprapatellar pouch (a partof the synovial cavity) and the two infrapatellar bur-sae, one located above and one located below thepatellar tendon.

MANEUVER: The prepatellar bursa is palpated forwarmth, focal tenderness, and swelling, and thewalls are squeezed between the fingertips to assessfor bursal wall thickening. After the acute andchronic inflammatory changes are noted, the rangeof motion of the knee is assessed.

INTERPRETATION: Acute bursitis is characterized by cystic swelling and varying degrees of tender-ness, warmth, and redness. Chronic bursitis is char-acterized by palpable thickening of the bursalwalls. The range of motion of the knee should bepreserved unless a secondary cellulitis complicates the case of septic bursitis.

FIGURE 11–8. Inspect the prepatellar bursa for swellingand thickening.

ANSERINE BURSA

SUMMARY: The anserine bursa is located betweenthe MCL and the conjoined tendon formed by thegracilis, sartorius, and semitendinosus tendons. Theentire tibial plateau is palpated to distinguish the localized tenderness of anserine bursitis from the more extensive tenderness of the MCL.

MANEUVER: The patella and the tibial tubercle aremarked with a pen. Medial midline tenderness atthe level of the tibial tubercle is compared with ten-derness at the medial joint line and medial femoralcondyle.

INTERPRETATION: A quarter-sized area of tender-ness in the concavity of the medial tibial plateauand at the level of the tibial tubercle is the classiclocation of anserine bursitis. Tenderness that ex-tends from the anserine bursal area to the joint line probably is caused by irritation or injury to the MCL.

FIGURE 11–9. Palpate the anserine bursa for local tendeness.


TRIAGE TO X-RAY For the patient who has sustainedan injury or is at risk of bony injury or the patient in whompatellofemoral syndrome or osteoarthritis is suspected onclinical grounds:

• Order posteroanterior and lateral views of the knee for pa-tients with a history of injuries or direct blow to the knee(distal femur fractures, patellar fracture, tibial plateau orproximal tibial fracture, or proximal fibular fracture).

• Order bilateral standing anteroposterior x-rays for patientsat risk for accelerated wear (to define the degree of os-teoarthritic changes in the medial and lateral compartments).

• Order bilateral sunrise or Merchant views of the patellafor younger patients with bilateral anterior knee pain(patellar subluxation and patellofemoral syndrome).

• Order specialized tunnel views for patients with mechani-cal symptoms (osteochondritis dissecans or intra-articularloose body).

TRIAGE TO THE LAB For patients suspected of havinginflammatory or septic effusion or suspected gouty or septicprepatellar bursitis:

• Order a complete blood cell count, uric acid, erythrocytesedimentation rate, blood cultures, and screening culturesfor gonorrhea for patients with acute pain, exquisite ten-derness, inability to weight bear, and large, actively in-flamed knee effusions (e.g., rheumatoid arthritis, gout,pseudogout, gonorrhea, septic arthritis).

• Order a complete blood cell count, uric acid, erythrocytesedimentation rate, and blood cultures for patients withacute inflammatory or septic prepatellar bursitis (gout,pseudogout, Staphylococcus aureus).

CONSIDER A BONE SCAN To investigate suspectedmetastatic involvement of the femur or tibia or to evaluatefor subtle bony fracture.

CONSIDER MR IMAGING For patients with dramaticathletic injuries, acute hemarthrosis following trauma, andsignificant mechanical symptoms such as loss of smooth mo-

tion or an inability to duck waddle (loose body, meniscaltear, cruciate ligament injury, or osteochondritis dissecans).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate knee pain and stiffness, fullrange of motion, normal alignment, normal gait, and nomore than a mild effusion:

• Limit walking, standing, and impact.• Avoid bending the knee more than 90 degrees (sitting,

sleeping, exercising).• Wear comfortable, properly fitted shoes with padded in-

soles to reduce the effects of impact.• Apply ice and elevate the knee four times a day.• Perform gentle daily straight leg raise to enhance the

quadriceps and hamstring muscle tone.• Use a patellar restraining brace with fabric stays during the

day (optional).• Recommend an anti-inflammatory medication for 10 to


7 days (optional).

DETAILED EXAMINATION: SPECIFIC KNEEDIAGNOSES

Perform a detailed examination of the knee for patients withpersistent or eluonic symptoms, moderate to severe kneepain and stiffness, antalgic gait, and acute loss of range ofmotion.

PATELLOFEMORAL SYNDROME The diagnosis ofpatellofemoral syndrome, the leading cause of knee pain in pa-tients under age 45, is based on a history of anterior knee pain exacerbated by repetitious flexion and an exam that demonstratesretropatellar pain and crepitation (e.g., grinding, clicking) whenthe patella is vigorously compressed against the walls of thefemoral groove. Irritation to the patellar cartilage is caused by un-even tracking of the patella in the femoral groove (lateral subluxa-tion). The sunrise view of the patella is used to determine the sever-ity of subluxation and degree of chronic wear.


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BILATERAL SUNRISE X-RAYS

SUMMARY: Bilateral x-rays allow comparison of thealignment of the patellae in the femoral grooves(subluxation), the articular width of the medial andlateral cartilage, and evaluation of subchondralbony thickening.

CASE: Bilateral sunrise views demonstrate moderatesubluxation, thinning of the lateral patellar carti-lage, thickening of the subchondral bone, and therare finding of osteochondritis dissecans on the left.

INTERPRETATION: X-rays of the early presentation of patellofemoral syndrome are normal. As the condition progresses, lateral subluxation develops, followed by progressive wear of the cartilage, sub-chondral bony thickening, osteophyte development,and in rare cases osteochondritis dissecans withloose body.

FIGURE 11–11. Bilateral sunrise x-rays to confirmpatellofemoral subluxation, arthritis, and so forth.

PATELLAR COMPRESSION

SUMMARY: The patella is the largest sesamoid boneof the body, normally centered over the distalfemoral groove and embedded in the large tendonof the quadriceps muscle. Patellofemoral syndrome,the constellation of signs and symptoms resultingfrom subluxation, results from the overly developedvastus lateralis muscle and the lateral forces causedby the quadriceps (the Q-angle).

MANEUVER: The patella is grasped firmly andmoved back and forth and up and down in thegroove of the femur. An abnormal response shouldreproduce the patient’s pain. Crepitation can be re-produced when the patella is compressed forcefullyagainst the femur.

ADDITIONAL SIGNS: Anterior knee clicking withpassive flexion of the knee is felt over the patella.The patient either refuses or hesitates to perform theInsall maneuver, a nonspecific sign recreating theabnormal patellofemoral tracking (the quadriceps is relaxed, the patella is forced into the inferior por-tion of the femoral groove, and then the patient isasked to contract the quadriceps, dragging thepatella through the groove). The range of motion of the knee is unaffected unless a knee effusion ispresent.

INTERPRETATION: Focal chondromalacia begins inthe inferior aspect of the femoral groove. To identifythe early presentation of this condition, emphasis isplaced on compression of the patella in the inferioraspect of the groove. As the condition progresses,pain and crepitation can be demonstrated over theentire articulation (pan patellar disease).

FIGURE 11–10. Perform patellar compression to assesspatellofemoral syndrome.

MEDIAL COMPARTMENT OSTEOARTHRITIS Of the threecompartments of the knee (medial, lateral, and patellofemoral) themedial compartment is most susceptible to age-related wear. Thismildly inflammatory arthritis is characterized by medial joint linetenderness, joint line crepitation, palpable tibial plateau spurs,


and varying degrees of knee effusion. The diagnosis can be con-firmed by measurement of the medial articular width obtainedfrom a weight bearing posteroanterior view of the knee or by directvisualization using arthroscopy.

JOINT LINES

SUMMARY: The normal carriage angle of the kneeis 8 to 10 degrees valgus, a necessary angle to al-low the femur to articulate with the pelvis at 135degrees. This angle causes an asymmetrical pres-sure on the medial compartment of the knee.

MANEUVER: The superior and inferior poles of thepatella are identified and marked. The joint linesare located at the level of the inferior pole of thepatella in the midplane of the femur. Local tender-ness medially is compared with the joint line tender-ness laterally.

ADDITIONAL SIGNS: Passive flexion and extensionof the knee can cause a grinding sensation (crepita-tion). Full flexion may be limited by advancedarthritic changes or the presence of an effusion.Secondary anserine bursitis or a mild MCL strain issuggested by more widespread areas of tendernessalong the medial side of the knee. Lack of full ex-tension suggests advanced arthritic change or thepresence of a degenerative meniscal tear or loosebody. The varus–valgus rocking maneuver of thetibia against the femur is loose because of the thin-ning of the medial cartilage.

INTERPRETATION: Tenderness at the joint line ismost commonly caused by irritation of the synovialmembrane (e.g., osteoarthritis, inflammatory arthri-tis). However, the local tenderness characteristic ofmeniscal and collateral ligament injuries overlapswith the joint line tenderness of arthritis.

FIGURE 11–12. Palpate the joint lines to assess the medialand lateral compartments of the knee.

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BILATERAL WEIGHT-BEARING X-RAYS

SUMMARY: Bilateral posteroanterior weight-bearingviews of the knee performed on a single cassette al-low a direct comparison of the degree of arthriticwear of the main knee joint. Normally, the width ofthe medial compartment cartilage, measured at thecenter of the femoral condyle, should be equal toor 1 mm greater than the width of the lateral com-partment cartilage.

CASE: This x-ray demonstrates advanced narrowingof the medial compartment, a loss of the normal 8- to 10-degree valgus carrying angle (measuredhere at 0 degrees), and mild subchondral bonythickening. Notice the absence of osteophytes.

INTERPRETATION: The severity of osteoarthritis cor-relates directly with the width of the articular carti-lage. The presence of joint line osteophytes, sub-chondral sclerosis or cystic degeneration, andmeniscal calcification vary from patient to patientand are not necessary to confirm the diagnosis. Thenormal medial cartilage width averages 6 to 8 mmdepending on sex, body frame, and so forth.

FIGURE 11–13. Bilateral weight-bearing x-rays to deter-mine the degree of medial and lateral compartment osteoarthritis.

KNEE EFFUSION Of the various maneuvers used to detect thepresence of a knee effusion, estimation of the lost of flexion by theheel-to-buttock measurement is the most reliable because it can beapplied to all patients regardless of size. Full flexion of the knee isimpaired whenever a knee effusion develops acutely. A 1- to

2-inch difference between the right and left heel-to-buttock measure-ments correlates directly with the presence of an acute effusion.Other much less common causes of impaired flexion include priorsurgery, an intra-articular fracture, advanced osteoarthritis, or alarge, palpable Baker cyst.


ASPIRATE THE KNEE JOINT

SUMMARY: The evaluation of the knee accompa-nied by joint effusion is incomplete until the syn-ovial fluid is obtained for laboratory analysis. The lateral approach to the knee is preferred be-cause the synovial cavity distends laterally in 75%of patients.


SURFACE ANATOMY: Lateral patella, superior patel-lar pole, iliotibial band, and distended synovialcavity.

POINT OF ENTRY: Laterally, halfway between theundersurface of the patella and the middle of the iliotibial track.



DEPTH: 1⁄2 to 3 inches.

ANESTHESIA: Ethyl chloride, skin: 1 mL to the lat-eral retinaculum; 1 mL intra-articularly.

FIGURE 11–15. Aspirate the knee joint to determine thecause of the knee effusion.

HEEL-TO-BUTTOCK MEASUREMENT

SUMMARY: Loss of flexion is the most reliablemeans of evaluating the knee for the presence ofexcess synovial fluid. The heel-to-buttock distance is a convenient and easy method to distinguishside-to-side differences in flexion. Of all the meansof assessing excess fluid production, this is the onlymethod that is reliable enough to use in obese patients.

MANEUVER: The knee is passively flexed. The pa-tient’s tolerance of the maneuver is noted. The dis-tance between the posterior heel and the buttocks is measured.

ADDITIONAL SIGNS: Loss of the peripatellar dim-ples, ballottement of fluid, the side-to-side milkingmaneuver, and suprapatellar fullness are additionalsigns of excess fluid.

INTERPRETATION: In the asthenic patient the firstsign of access fluid is the general fullness about theknee and the loss of the peripatellar dimples. Withincreasing amounts of fluid the ballottement signsand milking maneuvers become abnormal. Onlythe largest fluid accumulations extend above anddistend the suprapatellar extension of the synovialcavity.

FIGURE 11–14. Perform the heel-to-buttock measurementto assess knee effusion.

PREPATELLAR BURSITIS Acute prepatellar bursitis (inflam-mation of the largest knee bursa) is characterized by varying degrees of palpable swelling, focal tenderness, erythema, andwarmth, all centered over the lower half of the patella. Because the swelling is completely extra-articular, the range of motion of

the knee is unimpaired. In approximately 5% of these acute cases,the inflammatory process fails to resolve. Chronic prepatellar bur-sitis is characterized by palpably thickened bursal walls, focal ten-derness, and less dramatic signs of inflammation.

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PALPATE THE PREPATELLAR BURSA

SUMMARY: The bursa is one of four synovial linedstructures that lubricate the quadriceps mechanism.The other three are the suprapatellar pouch (a partof the synovial cavity) and the two infrapatellar bur-sae, one located above and one located below thepatellar tendon.

MANEUVER: The prepatellar bursa is palpated forwarmth, focal tenderness, and swelling, and thewalls are squeezed between the fingertips to assessfor bursal wall thickening.

ADDITIONAL SIGNS: The range of motion of theknee is unaffected unless a secondary cellulitis ispresent.

INTERPRETATION: Acute bursitis is characterized bycystic swelling and varying degrees of tenderness,warmth, and redness. Chronic bursitis is character-ized by palpable thickening of the bursal walls.These changes are located over the lower third ofthe patella, in contrast to the infrapatellar bursa,which is located exclusively over the patellar tendon.FIGURE 11–16. Palpate the prepatellar bursa for swelling

and thickening.

ASPIRATE THE BURSA

SUMMARY: Aspiration and laboratory analysis ofthe fluid are necessary to distinguish bursitis causedby trauma, crystal deposition disease (gout), or infection.


SURFACE ANATOMY: Lateral patella, superior patel-lar pole, iliotibial band.

POINT OF ENTRY: Laterally, halfway between theundersurface of the patella and the middle of the iliotibial track.



DEPTH: 1⁄2 to 3 inches.

ANESTHESIA: Ethyl chloride, skin: 1 mL to the lat-eral retinaculum; 1 mL intra-articularly.

FIGURE 11–17. Aspirate the bursa to distinguish the threecommon causes of prepatellar bursitis.

LATERAL COMPARTMENT OSTEOARTHRITIS Althoughlateral compartment osteoarthritis commonly accompanies medialcompartment osteoarthritis, isolated involvement does occur butalmost always results from a previous injury (lateral meniscal tear,

tibial plateau fracture, or grade-three ligament tears). The diagno-sis is suggested by a history of injury, lateral joint line tendernessand crepitation, palpable spurring along the lateral tibial plateau,and varying degrees of joint effusion.


WEIGHT-BEARING X-RAYS

SUMMARY: Less than 5% of patients with osteo-arthritis have exclusive involvement of the lateralcompartment.

CASE: This 54-year-old former lineman for theOregon State University football team injured hislateral meniscus at age 20. Meniscectomy was per-formed, and the patient was able to return to activeplay. Over the last several years the patient hashad chronic knee pain, an occasional giving-outsensation, and intermittent swelling.

INTERPRETATION: The absolute criterion for os-teoarthritis of the lateral compartment is a loss ofarticular cartilage measured on weight-bearing x-rays of the knee. The presence of joint line osteo-phytes, subchondral sclerosis or cystic degenera-tion, and meniscal calcification confirm the diag-nosis of osteoarthritis but do not universallyaccompany thinning of the articular cartilage. Thenormal width of the articular cartilage is 5–7 mm.

FIGURE 11–19. Weight-bearing x-rays confirm lateral com-partment osteoarthritis.

LATERAL JOINT LINE TENDERNESS

SUMMARY: Lateral knee pain encompasses irritation ofthe lateral compartment of the knee, injury to the LCL,lateral meniscal disorders, or iliotibial band inflamma-tion. Local tenderness limited to a dime-sized area atthe level of the inferior pole of the patella is caused byintrinsic conditions affecting the lateral compartment ofthe knee or the lateral meniscus.

MANEUVER: The superior and inferior poles of thepatella are identified and marked. The joint lines arelocated at the level of the inferior pole of the patella inthe midplane of the femur. Local tenderness laterally iscompared with the joint line tenderness medially.

ADDITIONAL SIGNS: Passive flexion and extensionof the knee can cause a grinding sensation (crepita-tion). Full flexion may be limited by advancedarthritic changes or the presence of an effusion.Secondary anserine bursitis or a mild LCL straincan accompany the arthritic flareup. Lack of full ex-tension suggests advanced arthritic change or thepresence of a degenerative meniscal tear or loosebody. The varus–valgus rocking maneuver of thetibia against the femur is loose because of the thin-ning of the lateral cartilage.

INTERPRETATION: Tenderness at the joint line ismost commonly caused by irritation of the synovialmembrane (e.g., osteoarthritis, inflammatory arthri-tis). However, meniscal and collateral ligament in-juries have local tenderness that overlaps with thejoint line tenderness.

FIGURE 11–18. Lateral joint line tenderness suggests lat-eral compartment osteoarthritis.

ANSERINE BURSITIS The diagnosis of anserine bursitis re-quires local tenderness confined to a quarter-sized area of the medialtibial plateau, approximately 11⁄2 inches below the medial joint line;a negative valgus stress maneuver (indicating an intact MCL);

and a normal x-ray of the tibia (no underlying bony disorder). The diagnosis can be confirmed by placing 1⁄2 mL local anesthetic between the medial collateral ligament and the conjoined tendon, approximately 3 to 4 mm above the periosteum of the tibia.

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ANSERINE BURSA

SUMMARY: The anserine bursa is located betweenthe MCL and the conjoined tendon formed by thegracilis, sartorius, and semitendinosus tendons.

MANEUVER: The patella and the tibial tubercle aremarked with a pen. Bursal tenderness at the level ofthe tibial tubercle is compared with tenderness at themedial joint line and medial femoral condyle. Thetenderness of the bursa should be limited to a quarter-sized area, as compared with the local tendernessof the MCL, which extends several centimeters fromthe joint line down to the area of the anserinebursa.

ADDITIONAL SIGNS: Valgus stress applied to thejoint should be pain free. Range of motion of theknee should be normal, and the joint line should bepainless unless anserine bursitis is a complication of osteoarthritis (a common occurrence).

INTERPRETATION: A quarter-sized area of tender-ness at the level of the tibial tubercle is the classiclocation of anserine bursitis. Tenderness that ex-tends from the anserine bursal area to the joint lineprobably is caused by irritation or injury involvingthe MCL

FIGURE 11–20. Palpate the anserine bursa for local tenderness.


SUMMARY: Local anesthetic block is used to deter-mine the contribution of bursitis to the patient’soverall pain level (anserine bursitis often accompa-nies osteoarthritis, joint effusion, or any primary diagnosis that causes an impaired gait).


SURFACE ANATOMY: Tibial tubercle, medial tibialplateau, and medial joint line.

POINT OF ENTRY: Midplane, at the level of the tib-ial tubercle or 1.5 inches below the medial jointline.

ANGLE OF ENTRY: Perpendicular to the curvature of the tibial plateaus.



ANESTHESIA: Ethyl chloride, skin: 1⁄2 mL 3 to 4 mmabove the tibial periosteum.

FIGURE 11–21. Local anesthetic block to confirm anserinebursitis.

MCL INJURY All MCL injuries are characterized by local ten-derness extending from the medial femoral condyle across the jointline to its attachment to the medial tibial plateau, pain and vary-ing degrees of laxity during valgus stress testing (first degree, no

laxity; second degree, mild to moderate laxity; third degree, dis-ruption and unstable), and pain with passive external rotation(variable).



SUMMARY: This procedure is nearly identical to theinjection of the anserine bursa, with the exceptionof the point of entry. It is used to distinguish MCLinjury from involvement of the medial meniscus, os-teoarthritis of the medial compartment, and anser-ine bursitis.


SURFACE ANATOMY: Tibial tubercle, medial tibialplateau, medial joint line.

POINT OF ENTRY: Enter in the midline over the tib-ial plateau just below the joint line.

NEEDLE: 5⁄8 inch, 25 gauge or 11⁄2 inch, 22 gauge.

DEPTH: 1⁄2 inch (thin patients) to 3⁄4 inch, or 1⁄8 inchjust above the periosteum of the tibia.

VOLUME: 1 to 2 mL anesthetic.

NOTE: Never inject between the MCL and thebone, and always brace after injection.

FIGURE 11–23. Local anesthetic block to confirm MCL injury.

VALGUS STRESS TEST

SUMMARY: Medial knee stability is maintained bythe quadriceps muscle, the joint capsule, and theMCL. The valgus stress test is used to determine the integrity of the MCL.

MANEUVER: One hand is placed above the kneealong the lateral thigh, and one hand is placedalong the medial gastrocnemius muscle. The upperhand is used to stabilize the thigh while the lowerhand exerts outward pressure on the calf. Pain,movement of the medial joint space, and elasticityof the ligament are noted.

ADDITIONAL SIGNS: Local tenderness extends from the upper tibial plateau (the same area as the anserine bursa), across the joint line, and to the medial femoral condyle.

INTERPRETATION: Pain without abnormal movementof the joint indicates a first-degree sprain. Pain withopening of the joint but rapid return to normal posi-tion characterizes a second-degree sprain or partialtear. Pain and persistent looseness or frank instabil-ity of the joint are characteristic of a third-degreesprain or complete tear. A false positive test can beseen with wear of the medial articular cartilage(medial compartment osteoarthritis with ligamentlaxity caused by compartmental narrowing).

FIGURE 11–22. Valgus stress test of MCL injury.

LCL INJURY LCL injuries are uncommon. The diagnosis issuggested by an injury involving dramatic varus stress, an exami-

nation demonstrating tenderness along the lateral joint line, andpain or laxity that is aggravated by varus stress testing of the knee.

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VARUS STRESS TEST

SUMMARY: Lateral stability of the knee is main-tained by the quadriceps muscles, the joint capsule,and the LCL. The varus stress test is used to deter-mine the integrity of the LCL.

MANEUVER: One hand is placed above the kneemedially, and one hand is placed along the lateralgastrocnemius muscle. The upper hand is used tostabilize the thigh while the lower hand exerts in-ward pressure on the calf. Pain, movement of thelateral joint space, and the elasticity of the ligamentare noted.

ADDITIONAL SIGNS: Local tenderness is presentalong a line extending from the fibular head,across the joint line, to the lateral femoral condyle.The range of motion of the knee should be normal.

INTERPRETATION: Pain without abnormal movementof the joint indicates a first-degree sprain. Pain withopening of the joint but rapid return to normal posi-tion characterizes the second-degree sprain or par-tial tear. Pain and persistent looseness of the jointare characteristic of a third-degree sprain or com-plete tear.

FIGURE 11–24. Varus stress test of LCL injury.


SUMMARY: This procedure is used to distinguish LCLinjury from involvement of the lateral meniscus andosteoarthritis of the lateral compartment.


SURFACE ANATOMY: Fibular head, lateral jointline, the iliotibial band demarcating the level of themidplane.

POINT OF ENTRY: Enter in the midplane just abovethe fibular head and just below the joint line.

NEEDLE: 5⁄8 inch, 25 gauge or 11⁄2 inch, 22 gauge.

DEPTH: 1⁄2 inch (thin patients) to 3⁄4 inch, or 1⁄8 inchjust above the ligament.

Volume: 1 to 2 mL anesthetic.

NOTE: Never inject between the LCL and the bone,and always brace after injection.

FIGURE 11–25. Local anesthetic block to confirm LCL injury.

ACL INJURY ACL injuries are uncommon in the nontrauma-tized patient. The diagnosis should be suspected if the patient hassustained a significant injury, describes symptoms of instability

(e.g., looseness, unexplained giving out), and experiences pain andlaxity with the Lachman maneuver or the anterior drawer sign.


MRI OR ARTHROSCOPY

SUMMARY: The cruciate ligaments are named fortheir attachments to the tibial spines. The photo-graph depicts the posterior cruciate ligament (ar-row). Both ligaments originate from the distal femurand traverse the intercondylar notch.

CASE: The 28-year-old patient sustained a hyperexten-sion injury and describes a vague, unstable sensationwith knee flexion. The patient presented with a tenseeffusion of the knee, which on aspiration was ahemarthrosis. The drawer and Lachman maneuverswere equivocal. Based on the injury, the presence ofintra-articular bleeding, and the subtle irregularitieson MRI, the patient underwent arthroscopy, whichdemonstrated a partially torn PCL.

INTERPRETATION: Depending on the severity of theinjury, the persistence of symptoms, and the subtlechanges on the knee exam, the clinician mustchoose between MRI and arthroscopy to evaluatethe integrity of the cruciate ligaments. The direct vi-sualization of the ligaments by arthroscopy has agreater sensitivity in determining the integrity of thecruciate ligaments.

FIGURE 11–27. MRI or arthroscopy to confirm injury to thecruciate ligaments.

ANTERIOR DRAWER SIGN

SUMMARY: The ACL is located in the intercondylarnotch of the femur and is named for its attachment atthe anterior tibial spine. Its function is to prevent theanterior movement of the tibia relative to the femur.

MANEUVER: The proximal tibia is grasped firmlywith both hands. While stabilizing the foot, the ex-aminer forcefully pulls the tibia anteriorly, notingany pain, laxity, or abnormal movement comparedwith the contralateral side.

ADDITIONAL SIGNS: The Lachman maneuvershould corroborate a positive drawer sign. A tensehemarthrosis may be present. Additional injuriessuch as an MCL or meniscal tear may be present.

INTERPRETATION: A difference of 1 cm between theanterior drawer signs suggests complete tear of theligament. Partial tears are characterized by pain,loss of elasticity, and poor springback with theLachman maneuver (the latter maneuver is identicalto the anterior drawer sign with the exception ofholding the foot fast to the exam table).

FIGURE 11–26. Anterior drawer sign to evaluate the in-tegrity of the ACL.

BAKER’S CYST A Baker’s cyst, also called a popliteal cyst, is a direct result of excessive synovial fluid production (chronic kneeeffusions associated with rheumatoid arthritis, advanced os-teoarthritis, and so forth). Large cysts (more than 4 cm long) inter-

fere with full flexion of the knee. Patients who complain ofpopliteal tightness, fullness behind the knee, or impairment of bending have a large knee effusion, a Baker’s cyst, or both.

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POPLITEAL FOSSA

SUMMARY: All synovial fluid is produced anteriorlyby the joint capsule. As excess fluid accumulates, theperipatellar dimples begin to fill in, the patella floatsabove the femoral groove, and eventually the fluidextends into the suprapatellar portion of the synovialcavity. Repetitive flexing of the knee forces the fluidthrough a sinus into the popliteal fossa, distendingthe semimembranosus bursa. With continued disten-sion and the hydraulic pressure of flexion, the bursagradually enlarges and eventually seals itself offfrom its connection with the synovial cavity. Whenthe sinus finally collapses, a true Baker’s cyst forms.

MANEUVER: Two hands are used to palpate the medialside of the popliteal fossa for a cystic or pulsatile mass.

ADDITIONAL SIGNS: Signs of the underlying effu-sion and its primary cause are present in mostcases. If the Baker’s cyst has ruptured, calf tender-ness and bruising may be present at the ankle (the crescent sign located behind the malleolus).

INTERPRETATION: A sensation of pressure or full-ness in the popliteal fossa is most often associatedwith a joint effusion. The differential diagnosis ofpopliteal mass includes large posterior fat pads,Baker’s cyst, and popliteal aneurysm.

FIGURE 11–28. Palpate the popliteal fossa for a Baker’s cyst.

ASPIRATION

SUMMARY: A painless mass is palpable in thepopliteal fossa. Needle aspiration is used to confirm the diagnosis and to reduce the pressureon the structures of the popliteal fossa.

POSITIONING: Prone.

SURFACE ANATOMY: Popliteal fossa and kneecreases, semimembranosus and semitendinosus tendons.

POINT OF ENTRY: Directly over the center of thepalpable cyst.



Depth: 1⁄2 to 3⁄4 inches.


FIGURE 11–29. Aspiration to confirm a Baker cyst.

MENISCAL TEAR The symptoms and signs of meniscal tear of-ten are vague and nonspecific. The pain is not well localized or de-fined. The exam may demonstrate a loss of smooth motion, a

small, bland effusion of the knee, and minor joint line tenderness,symptoms that overlap with those of other conditions. After athorough examination of the knee, MRI or diagnostic arthroscopy


MRI OR ARTHROSCOPY

SUMMARY: The disk-shaped meniscal cartilages arecomposed of fibrocartilage and provide smooth mo-tion between the two bones. Patients with substan-tial injuries to the cartilage often describe a vaguesense of instability, especially with repeated kneeflexion. Occasionally the patient complains of loudpopping sounds when attempting to squat. De-pending on the severity of the injury, the persis-tence of symptoms, and the subtle changes onexam of the knee, the clinician must choose be-tween MRI and arthroscopy to evaluate the integrityof the meniscal cartilage.

DIAGNOSIS: A complex medial meniscal cartilagetear extending to the articular surface of the tibia.

INTERPRETATION: Mucinoid degeneration of themeniscal cartilage develops with age. These ap-pear as increased signal arising from the center ofthe meniscus on MRI. This age-related phenomenonmust be distinguished from the much more signifi-cant traumatic meniscal tears that extend to the articular surface (arrow).

FIGURE 11–31. MRI or arthroscopy to confirm a meniscaltear.

MCMURRY MANEUVER

SUMMARY: The McMurry maneuver attempts to trapthe torn meniscus between the tibia and the femur.A positive maneuver occurs when the cartilage sud-denly dislodges, causing a popping at the jointline. Unfortunately, it screens only for posterior orposterolateral meniscal tears. The McMurry maneu-ver cannot detect anterior or anterolateral tears,making this test inherently difficult to interpret.

MANEUVER: The examiner’s thumb and index fin-gers are placed on the medial and lateral jointlines. The knee is passively flexed. While applyingtorque to the foot, the examiner rotates the kneemedially to trap the lateral meniscus or laterally totrap the medial meniscus. The knee is passively ex-tended. The examiner repeats the maneuver in asmooth back-and-forth motion, feeling for a pop-ping sensation along the joint line.

ADDITIONAL SIGNS: Joint line tenderness is invari-ably present. Knee effusion accompanies the moresignificant meniscal tears. ACL and MCL injuriescan accompany meniscal tears. Large, fragmentedmeniscal tears can cause locking or incomplete extension of the knee.

INTERPRETATION: The sensitivity of the McMurry ma-neuver is limited because the maneuver is incapable oftrapping most anterior and anterolateral tears. A nega-tive test cannot be used to rule out a meniscal tear.

FIGURE 11–30. Perform a McMurry maneuver to assess formeniscal tear.

can be considered in patients who have sustained an injury, com-plain of persistent impairment of function (giving out, a sense of

instability, or a loss of smooth motion), and demonstrate the subtleabnormalities on examination.

ILIOTIBIAL BAND SYNDROME Iliotibial band syndrome isseen almost exclusively in runners. The diagnosis should be consid-ered in an athletic patient with focal tenderness with or without

palpable clicking over the lateral femoral condyle. X-rays of the fe-mur usually are normal, and the knee exam is otherwise normal.

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LATERAL FEMORAL CONDYLE

SUMMARY: The iliotibial band is a broad, thick fas-cia that forms the distal portion of the tensor fascialata and the vastus lateralis fascia. It crosses theprominence of the lateral femoral condyle to attachto the fibular head. It blends with the lateral patel-lar retinaculum near the lateral joint line.

MANEUVER: The superior, inferior, and lateral polesof the patella are palpated and marked with a pen.The iliotibial band is palpated over the lateralfemoral condyle, located at the same level as thesuperior pole of the patella. The inch-wide band isbest identified by palpation in a downward direc-tion toward the popliteal area.

ADDITIONAL SIGNS: Passive flexion and extensionof the knee can be associated with a snapping sen-sation of the band across the femoral condyle.

INTERPRETATION: Local tenderness over the lateralfemoral condyle in a nontraumatized patient is nearlyalways caused by iliotibial band syndrome. Plain x-rays are used to exclude primary or secondarybony lesions of the condyle. However, these bony le-sions rarely have the same precise area of tender-ness at the intersection of the band and the femoralcondyle as seen with iliotibial band syndrome.

FIGURE 11–32. Palpate the lateral femoral condyle to as-sess the iliotibial band.


SUMMARY: The quarter-sized area of tenderness at the lateral femoral condyle usually is diagnosticof iliotibial band syndrome. When the tendernesslacks the characteristic location or size, local anes-thetic block is performed to distinguish the symp-toms arising from the iliotibial band from involve-ment of the LCL and lateral compartment of theknee.


SURFACE ANATOMY: Lateral patella, superior patel-lar pole, iliotibial band, and lateral femoralcondyle.

POINT OF ENTRY: Over the lateral femoral condyle.

ANGLE OF ENTRY: Perpendicular.



ANESTHESIA: Ethyl chloride, skin: 1 mL above andbelow the iliotibial band.

FIGURE 11–33. Local anesthetic block to confirm iliotibialband injury.

PAIN REFERRED TO THE KNEE The back, sacroiliac joint,and hip commonly refer pain to the knee. The L5 root andsacroiliac joint refer pain down the back of the leg to the poplitealspace. The S1 root, the trochanteric bursa, and the femur referpain down the outer thigh to the lateral area of knee. The hip

joint and the femur refer pain down the front of the thigh to theanterior knee. Referred pain is suggested whenever the patient’spain is not well localized, the knee exam is free of local tendernessor inflammatory changes, and the flexion and extension of theknee are normal.


CT OR MRI

SUMMARY: CT scanning or MRI is necessary to define the anatomic process causing lumbar radiculopathy.

CASE: This 62-year-old man complained of painrunning down the back of the leg to the knee and a tingling sensation on the bottom of the foot. Theankle reflex was diminished, but motor strength ofdorsiflexion and plantarflexion were normal.

DIAGNOSIS: Herniated disk at the L5–S1 level.

FIGURE 11–35. A definitive diagnosis of radiculopathy requiresdirect correlation of the neurodeficits defined by examination andCT or MRI studies.

STRAIGHT LEG RAISE MANEUVER

SUMMARY: Lumbar level L4–L5 and lumbar levelL5–S1 cause pain and numbness over the outerknee and popliteal areas, respectively. Moderateto severe trochanteric bursitis commonly refers pain to the lateral knee. Occasionally pain is referred tothe lower femur and anterior knee from conditionsaffecting the hip joint. Rarely, primary and sec-ondary lesions of the femur manifest pain at theknee. A referred pattern of pain should always be considered when local signs of knee swelling,tenderness, and impaired motion are absent (see Chapter 9 for details).

FIGURE 11–34. Straight leg raise maneuver to evaluatefor lumbar radiculopathy.



Pressure of the patella against the #1: Patellofemoral Bilateral sunrise views taken on one cassette to evaluate forfemur causing retropatellar pain and syndrome patellar subluxation and arthritic changescrepitation

Patellar clicking with passive flexion and extension

� Insall maneuver; retropatellar pain with quadriceps contraction

Patellar apprehension sign with lateral Patellar subluxation Clinical diagnosissubluxation or dislocation

Medial joint line tenderness or spurring #2: Medial compartment Standing anteroposterior knees on one cassette, showingosteoarthritis narrowing of the articular cartilage

Stiffness or incomplete flexion

Crepitation with passive flexion and extension

Heel-to-buttock measurement differs Knee effusion Aspiration and lab analysis for cell count, differential, crystals, side to side glucose, Gram stain, and culture

Loss of the peripatellar dimples

Synovial milking sign

Ballottement sign for large effusions

Distension of the suprapatellar pouch

Cystic swelling over the anteroinferior portion Prepatellar bursitis Aspiration and lab analysis for cell count, differential, crystals, of the patella glucose, Gram stain, and culture

No loss of range of motion

Thickening of the prepatellar bursa Chronic prepatellar bursitis Local anesthetic block in the bursa

No loss of range of motion

Lateral joint line tenderness or spurring Lateral compartment Standing anteroposterior knees on one cassette showing osteoarthritis narrowing of the articular cartilage

Stiffness or incomplete flexion

Crepitation with passive flexion and extension

Tenderness over the medial tibial plateau, Anserine bursitis Local anesthetic block in the 2–3 mm above the periosteum11⁄2 inch below the joint line

No pain with valgus stress testing

Normal range of motion of the knee

Line of tenderness over the medial tibial plateau Medial collateral ligament Empirical treatment with 3–4 wk of straight leg mobilization; extending up to or above to the medial joint line injury local anesthetic block placed just over the ligament (optional)

Pain aggravated by valgus stress testing

Pain aggravated by external rotation of the tibia on the femur

Tenderness over the lateral tibial plateau extending Lateral collateral ligament Improvement with 3–4 wk of straight leg immobilization; local along a line to the lateral joint line injury anesthetic block placed just over the ligament (optional)

Pain aggravated by varus stress testing

Pain aggravated by internal rotation of the tibia on the femur

Painful anterior drawer sign Anterior cruciate ligament Arthroscopy or MRIinjury

Pain or inability to fully squat and duck waddle

Palpable cyst in the medial side of the popliteal Baker’s cyst Characteristic aspiratefossa

Incomplete range of motion if the cyst is large

Distal edema

Joint line tenderness and mechanical locking or Meniscal tear Arthroscopy or MRIjoint line popping

Inability to duck waddle

Popping with squatting

Lateral femoral condyle tenderness Iliotibial band syndrome Local anesthetic block

Normal lateral collateral ligament exam

No active evidence of lateral compartment osteoarthritis

COMMON KNEE FRACTURES


FRACTURES OF THE PATELLA

SUMMARY: Patellar fractures are classified as trans-verse, stellate, longitudinal, marginal, and, rarely,osteochondral. More than half of the fractures aretransverse, and the majority of these are the resultof a direct blow to the patella that is magnified bythe tremendous pull of the quadriceps mechanism.Most show little or no separation of the fragmentsbecause of the intact medial and lateral quadricepsmuscle “expansions.”

IMMOBILIZATION: Nonoperative management in-cludes hemarthrosis aspiration and intra-articularanesthesia to accurately assess the integrity of thequadriceps mechanism, followed by long-leg cast-ing and gradual restoration of weight bearing(nondisplaced fractures).

SURGICAL REFERRAL: Refer to a surgical orthopedistif the quadriceps mechanism is ruptured or the frag-ments are separated by more than 2 mm. Surgeryinvolves cerclage wiring or lag screw internal fixa-tion for displaced fragments or total patellectomyfor the severely comminuted fracture.

PROGNOSIS: Severely displaced fractures increasethe risk of late-onset osteoarthritis.

FIGURE 11–37. Fractures of the patella.

DISTAL FEMUR AND PROXIMAL TIBIAL KNEEFRACTURES

SUMMARY: Because of the variety of fractures thatoccur at the knee (tibial plateau) and the distal fe-mur (supracondylar), the intra-articular extension ofa large proportion of these fractures, the associatedinjuries to the supporting ligaments, and the needfor specialized traction and cast-bracing, most pa-tients with these fractures should be referred to anorthopedic surgeon for management. Fractures thatcan be treated nonoperatively include avulsion frac-tures at the joint line (MCL and LCL injuries),nondisplaced osteochondritis dissecans fracturesthat do not cause mechanical locking, minimally de-pressed tibial plateau rim fractures (depression lessthan 10 degrees), and certain patellar fractures.

FIGURE 11–36. Distal femur and proximal tibial kneefractures.

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OSTEOCHONDRITIS DISSECANS

SUMMARY: Osteochondritis dissecans is an osteo-chondral fracture, a defect of cartilage and boneon the articular surface. As to its exact cause, di-rect trauma, ischemia, and true avulsion are theo-rized. Patients present with nonspecific knee com-plaints or with mechanical locking caused by anassociated loose body.

SURGICAL REFERRAL: Patients with large fragments,persistent knee effusion, and mechanical lockingshould be referred to orthopedic surgery to con-sider PCL repair, drilling of the fragment (to stimu-late revascularization), or repair of any other asso-ciated injuries to ligaments or meniscal cartilage.

PROGNOSIS: Large defects cause an acceleratedwear-and-tear osteoarthritis.

FIGURE 11–38. Osteochondritis dissecans of the femur.

FRACTURES OF THE TIBIAL SHAFT

SUMMARY: Because of the complexity, the need for specialized casting, and the potential complica-tions, most tibial shaft fractures should be managedby an orthopedic surgeon.

IMMOBILIZATION: Fractures with no more than 1cm of shortening, 5 degrees of varus or valgus an-gulation, or 10 degrees of anteroposterior or rota-tional angulation can be managed nonoperatively.After closed reduction using intravenous sedation, a long-leg cast with suprapatellar and medial tibialmolding is applied. The foot and ankle are kept in the neutral position, and the knee is flexed to 5 degrees. Healing time averages 5 months. Castwedging is used to correct any postreduction angu-lation. When adequate callus formation is noted on x-rays, the cast can be replaced with a patellartendon–bearing cast or brace to complete the healing process.

PROGNOSIS: During the recovery period, the pa-tient must be carefully monitored for deep venousthrombosis, anterior compartment syndrome, anddistal ischemia.

FIGURE 11–39. Fractures of the tibial shaft.


TIBIAL AND FIBULAR FRACTURES

SUMMARY: This combined fracture should be re-ferred to an orthopedic surgeon because of thepresence of instability, angulation, or major soft tissue injury.

IMMOBILIZATION: Isolated fibular shaft fracturesare much less common than the combined tibialand fibular fracture. It usually occurs as a result ofa direct blow. Immobilization is used for pain con-trol only. The fracture can be treated with a short-ened stride, decreased weight-bearing activities, orimmobilization with a short leg walking cast. Fixedimmobilization with casting is recommended whenweight-bearing pain is troublesome.

FIGURE 11–41. Combined tibial and fibular fractures.

TIBIAL STRESS FRACTURE

SUMMARY: Stress fractures of the tibia result fromrepeated microtrauma to the proximal third of thebone, often occurring in the section of the tibia withthe smallest cross-sectional area. The condition isseen almost exclusively in runners, professional bal-let dancers, and military recruits, although patientswith severe osteoporotic bones are also susceptible.Radiographically, the periosteum of the tibia isthickened in the proximal third of the bone in run-ners and in the middle third of the bone in balletdancers. A true fracture line is seen rarely. Stressfracture must be distinguished from the more com-mon shin splints, anterior compartment syndrome,and localized pain or paresthesia of the outerlower leg caused by lumbosacral radiculopathy.

IMMOBILIZATION: Running and other impact sportsmust be avoided for several weeks. Patients with severe pain should be advised to use crutches. Per-sistent cases can be treated with fixed immobiliza-tion with an air cast or short leg walking cast. In therecovery phase, nonimpact muscle toning exercisesare strongly recommended, and padded arch sup-ports are suggested for long-term prevention.

SURGICAL REFERRAL: None.FIGURE 11–40. Tibial stress fracture.

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• Lateral subluxation of the patella is the hallmark andmajor cause of patellofemoral syndrome, accounting forhalf the diagnoses in patients presenting with knee pain.

• The quadriceps mechanism, including the quadricepsmuscle, the patellar tendon, and the patellofemoral ar-ticulation, needs the greatest degree of lubrication inthe body. The largest synovial cavity, the prepatellarbursa, and the infrapatellar bursae surround these struc-tures to protect against friction and wear.

• Patients with osteoarthritis of the medial compartmentof the knee most often manifest symptoms when theunderlying arthritis is complicated by effusion, anserinebursitis, MCL injury, or degenerative meniscal tear.

• The earliest sign of osteoarthritis on weight-bearing x-rays of the knee is an equalization of the widths of themedial and lateral compartment cartilages (normally the medial compartment cartilage is 1 mm wider thanthe lateral compartment width, measured at the mid-femoral condyle).

• Osteoarthritis limited to the lateral compartment al-most always occurs as a long-term sequela of previoustrauma (fracture, meniscal tear, or ligament injury).

• The synovial cavity of the knee is the largest of all of thejoints of the body. Large effusions, ranging from 15 to60 mL, cause a loss of the peripatellar dimples (kneefullness), lift the patella off the femur (ballotablepatella), distend the superior pouch of the cavity up to4 inches above the superior pole (fullness above thepatella and a lateral bulge), and interfere with flexion ofthe knee (reduction of the heel-to-buttock distance, es-pecially when effusions develop acutely).

• Ten percent of all knee effusions are accompanied by adistension of the semimembranosus bursa and a trueBaker cyst when the sinus connecting the bursa and thesynovial cavity closes.

• Rupture of a true Baker cyst can cause symptoms iden-tical to the signs and symptoms of deep venous throm-bosis of the calf. The exception is the crescent sign atthe ankle, a collection of blood below the malleoli in-dicative of blood dissecting down the tissue planes ofthe calf to the ankle.

• Large knee effusions that extend into the popliteal spacecan cause lower extremity edema by compressing thepopliteal veins, and symptoms can mimic sciaticathrough pressure on the neurovascular bundle.

• Anserine bursitis results from any primary condition af-fecting the knee that alters the normal mechanics ofgait, mostly commonly, any diagnosis that leads to thedevelopment of a significant knee effusion. Becauseanserine bursitis develops secondarily, emphasis shouldbe placed on treating the main joint.

CLINICAL PEARLS

• It is impossible to distinguish acute, traumatic prepatel-lar bursitis from the inflammatory changes associatedwith septic or gouty bursitis. Therefore, all bursae mustbe aspirated for laboratory studies to avoid the difficul-ties in clinical decision making when empiric treatmentwith antibiotics fails to resolve the condition.

• Tendonitis of the patellar tendon (jumper’s knee) is seenalmost exclusively in athletes such as basketball and vol-leyball players and high jumpers.

• Ninety-five percent of patients with acute hemarthrosishave an underlying injury to ligament, meniscal carti-lage, or adjacent bone and therefore need MRI and re-ferral to a knee arthroscopist. The remaining patientshave bloody effusions caused by synovial capsule tearsor a bleeding diathesis caused by oral anticoagulation orhemophilia, all of which are reversible.

• Traumatic meniscal tears are distinctly different fromthe degenerative tears associated with aging and os-teoarthritis. The latter often respond to conservativemanagement of the knee, whereas the traumatic tears(often in younger athletic patients) warrant evaluationwith MRI and arthroscopy if function is impaired dramatically.

• Meniscal tears rarely cause true mechanical locking.Most patients describe a loss of smooth mechanicalfunction, complain of “something just not right insidemy knee,” or develop an unexplained knee effusion af-ter injury.

• McMurry and Apley maneuvers are quite specific formeniscal disorders but lack sensitivity (30% false nega-tives). MRI often overestimates meniscal disorders be-cause of the high incidence of mucinoid degenerativechanges. The decision to use diagnostic arthroscopyshould be predicated on the impairment of overall kneefunction, the need to define the cause of an unex-plained knee effusion (especially with normal radio-graphs of the knee), or in some cases, the demands ofthe athletic patient.

• Local anesthetic block is an integral part of the evalua-tion of the patient with ligament injury. The acute painof the injury and motion guarding must be controlledin order to distinguish second-degree sprains (partialtears) from third-degree sprains (complete, surgically re-pairable tears).

• Patients with advanced medial compartment os-teoarthritis of the knee are susceptible to MCL injuriesand medial meniscal tears. The MCL gradually loosensas the medial compartment cartilage wears away, caus-ing ever greater loosening of the joint (wobbling).

• ACL and PCL injuries are rare in patients with ad-vanced osteoarthritis.

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CHAPTER 12: ANKLE


Diagnoses

Ligaments (most common)Ankle sprain (1st, 2nd, 3rd degree)Ankle sprain with fibular avulsionAnkle sprain with peroneus tendon avulsion

fractureAnkle sprain with osteochondritis dissecans or

chondral fractureAnkle sprain with interosseus membrane disruptionAnkle sprain with instability

JointOsteoarthritis, posttraumaticInflammatory or septic arthritisSubtalar arthritis

Posterior heelAchilles tendonitisAchilles tendon rupturePre-Achilles bursitisRetrocalcaneal bursitisOs trigonum syndrome

Plantar heelHeel pad syndromePlantar fasciitisCalcaneal stress fractureSever’s disease (age less than 18 years)

TendonsPeroneus tenosynovitisPosterior tibialis tenosynovitis

Tarsal tunnel syndrome

Referred painLumbosacral spine radiculopathy

Compartment syndrome or shin splintsBaker’s cystAnkle fractures

Confirmations

Examination, x-ray (if indicated)Examination, x-ray: ankle seriesExamination, x-ray: ankle series

Examination, x-ray, magnetic resonance imaging (MRI)

Examination, x-ray: stress viewsExamination, x-ray: stress views

X-ray: ankle seriesAspiration and synovial fluid analysisExamination, local anesthetic block

Examination, MRIExamination, MRILocal anesthetic blockLocal anesthetic blockX-ray

ExaminationLocal anesthetic blockX-ray or bone scanningX-ray: ankle series

Local anesthetic blockLocal anesthetic block


Computed tomography (CT) scan, MRI, electromyelography

Calf examinationKnee examination, ultrasoundX-ray, bone scan, or MRI

INTRODUCTION The conditions affecting the anklecan be divided into three distinct areas—the true anklejoint, the posterior heel, and the plantar heel—based on thepatient’s description and location of their pain, the mech-anism of injury, and the anatomic structures most suscep-tible to injury. Of the structures that make up the anklejoint, the supporting ligaments and tendons are most sus-ceptible to injury; injury to the joint or its supporting softtissues causes true ankle pain. Of the anatomic structuresof the back of the ankle, the Achilles tendon mechanism ismost susceptible to injury; injury to any of the structuresof the back of the ankle causes posterior heel pain. And ofthe bones and ligamentous structures that form the arch ofthe foot, the plantar fascia is most susceptible to injury; in-jury to any of the structures forming the arch cause plan-tar heel pain.

Injury to the lateral supporting ligaments of the ankle isthe most common ankle condition. In most cases, the diag-nosis of ankle sprain is not difficult. However, distinguish-ing simple first- and second-degree ankle sprains from thecomplex third-degree ankle sprain remains the greatestchallenge. The primary care provider must remain vigilantto the complications that accompany the higher-degreesprains, including incomplete ligament healing and recur-rent ankle sprain, ankle instability, fibular avulsion frac-ture, peroneus avulsion fracture, peroneus tendonitis, ta-lar dome osteochondritis dissecans, and chondral fractureof the articular cartilage of the talus. Less common condi-tions at the ankle include arthritis of the true ankle joint,subtalar joint arthritis, and os trigonum syndrome.Despite the fact that the ankle carries nearly all the body’s weight, osteoarthritis of the ankle is uncommon. In-flammatory arthritis (chiefly rheumatoid arthritis) eventu-ally will affect the ankle joint in its progressive forms and isthe most common cause of subtalar arthritis.

Plantar fasciitis is the most common cause of plantarheel pain. It must be distinguished from the traumatic con-ditions affecting the heel, namely heel pad syndrome (thestone bruise of the calcaneus) and the common conditionsaffecting the calcaneus bone, stress fracture in adults andepiphysitis in children (Sever’s disease).

Injury to the Achilles tendon mechanism with or withoutpartial or complete rupture dominates the differential diag-nosis of posterior heel pain. Achilles tendonitis, partial tearof the tendon, and complete rupture must be distinguishedfrom the less common and often misdiagnosed pre-Achillesbursitis (the pump-bump) and the uncommon inflamma-tion of the bursal sac located between the tendon and theposterior aspect of the ankle joint, retrocalcaneal bursitis.

Unlike the other joints of the skeleton, trauma is a majorcause of the conditions affecting the ankle. For example,simple and complicated ankle sprains, Achilles tendonitisand tendon rupture, and ankle arthritis all result directlyfrom injury or are long-term sequelae of it. The primary carephysician must remain familiar with the types and mecha-nisms of the injuries associated with these common condi-tions in order to effectively triage the patients sufferingmore severe trauma. Early consultation with the fracturespecialist is necessary for patients sustaining ski injuries, ver-tical falls from significant heights, and crushing injuriesfrom motor vehicle accidents, who are at greater risk for cal-caneal and talar dome fractures, distal fibular fractures,

interosseous membrane rupture, and the bimalleolar andtrimalleolar fractures.

Finally, pain and numbness can be referred to the anklefrom the lower lumbar nerve roots, from tarsal tunnel syn-drome, or from the lower leg. Lumbar level L4–L5 and lum-bar level L5–S1 cause pain and numbness over the dorsumand plantar surfaces, respectively. Compression and irrita-tion of the posterior tibial nerve as it wraps around the me-dial malleolus cause pain to course through the ankle anddown to the plantar surface of the ball of the foot. Tibialstress fractures, primary bony lesions of the tibia, and shinsplints occasionally refer pain to the ankle.

SYMPTOMS Patients with intrinsic conditions affectingthe ankle most often complain of pain or difficulty with am-bulation. The location of the pain is the most useful fact innarrowing the possible anatomic diagnoses. The type andmechanism of injury and the effect of the injury on ambu-lation are used to determine the overall function of the an-kle and severity of the process.

Anatomically, patients typically describe their pain asarising from the general area of the ankle or the heel.Patients with ankle pain accurately define their pain as lat-eral, anterior, or medial. Similarly, patients with heel painaccurately define their pain as arising from the bottom ofthe heel (plantar) or behind the heel (posterior location).

Lateral ankle pain is the most commonly described pat-tern of pain. It is the classic area described by patients withinjury to the lateral ankle ligaments. The degree of injury tothe ligaments is defined by the effect on function. Patientswith uncomplicated, simple ankle sprains are able to bearweight or ambulate with little difficulty. By contrast, pa-tients with higher-degree ligament tears with or withoutavulsion fracture at the lateral malleolus or the base of thefifth metatarsal (the insertion of the peroneus tendon) havedramatic impairment of ambulation and weight bearing.Peroneus tenosynovitis and arthritis of the ankle are muchless common causes of lateral ankle pain.

Anterior ankle pain is the classic location of pain arisingfrom ankle arthritis, dorsotenosynovitis of the extensor ten-dons, and referred pain from shin splints or the tibia bone.

Medial ankle pain is the location of pain described withsubtalar arthritis (most often from advanced rheumatoidarthritis), posterior tibial tenosynovitis, and tarsal tunnelsyndrome.

Posterior heel pain is the location of pain arising fromthe Achilles tendon, the pre-Achilles bursa, the retrocal-caneal bursa, and os trigonum syndrome.

Plantar heel pain is caused by plantar fasciitis, heel padsyndrome, calcaneal stress fracture, and Sever’s disease.

Referred pain to the ankle is uncommon. Sciatica is themost common cause. Rarely, a intrinsic condition affectingthe knee can cause pain down the anterior lower leg.Occasionally shin splints refer pain over the anterior aspectof the ankle joint.

EXAMINATION The examiner assesses the generalfunction and integrity of the ankle by observing the pa-tient’s ankle alignment while standing, the patient’s abilityto bear weight, and the ability to perform normal heel–toe

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walking. These simple maneuvers provide a rapid assess-ment of the severity of the condition affecting the ankle.

For patients presenting with true ankle pain, the first pri-ority is to assess the integrity of the tibiotalar joints by eval-uating the range of motion of the joint, comparing flexionand extension from side to side. Normal range of motion is30 degrees of dorsiflexion and 60 to 70 degrees of plan-tarflexion. To evaluate the subtalar joint, the examiner com-pares passively performed inversion and eversion from sideto side. The examiner assesses ankle joint stability by stresstesting the deltoid ligaments medially, the interosseousmembrane, and the talofibular and fibulocalcaneal liga-ments laterally.

The examiner assesses ligament integrity by assessing lo-cal tenderness, passively stretching the ligaments in inver-sion and eversion, and noting endpoint stiffness and pain.Inflammation or rupture of the supporting tendons of theankle is evaluated by palpation and isometric stress testingof the tendons. By resisting inversion isometrically and pal-pating just under the medial malleolus, the examiner as-sesses the posterior tibial tendon. To assess the peroneustendons, the examiner resists eversion isometrically and pal-pates just under the lateral malleolus.

For patients presenting with posterior heel pain, the ex-aminer evaluates the Achilles tendon by palpating thelength of the tendon and by isometric stress testing. The ex-aminer assesses the pre-Achilles bursa by noting anyswelling and palpating the area over the superior aspect ofthe calcaneus, and the examiner evaluates the retrocalcanealbursa by noting any swelling between the Achilles tendonand the talus and compressing the bursa by forced, passiveplantarflexion.

For patients presenting with plantar heel pain, the exam-iner palpates the plantar fascia heel at its insertion on thecalcaneus. To assess injury and irritation of the heel pad, theexaminer squeezes the specialized fat from side to side, andto assess the integrity of the calcaneus, the examiner com-presses the bone from side to side.

ONE-MINUTE SCREENING EXAM: MANEUVERSASSESSING OVERALL ANKLE FUNCTION ANDDIFFERENTIAL DIAGNOSIS

The next seven maneuvers represent the minimal examina-tion of the patient presenting with ankle symptoms.Functional testing of ambulation and stance, range of mo-tion measurement of the joint, and screening maneuvers forligament injuries, posterior heel pain, and plantar heel painprovide enough information to triage to x-ray, order appro-priate labs, suggest general treatment recommendations, orproceed to more detailed examination and treatment.


Lateral ankle pain Ankle sprainAnkle sprain with instabilityAnkle sprain with chondral

fractureAnkle sprain with interosseous

membrane ruptureAnkle sprain with osteochon-

dritis dissecans of the talusAvulsion of the peroneus

tendonAvulsion fracture of the fibulaPeroneus tendonitis

Anterior ankle pain Ankle osteoarthritisInflammatory arthritisDorsotenosynovitis

Medial ankle pain Posterior tibialis tendonitisDeltoid ligament strainSubtalar arthritisTarsal tunnel

Posterior heel pain Achilles tendonitisAchilles tendon rupturePre-Achilles bursitisCalcaneal stress fractureRetrocalcaneal bursitisOs trigonum syndrome

Plantar heel pain Plantar fasciitisHeel pad syndromeCalcaneal stress fracture

Referred pain Lumbar radiculopathyTarsal tunnelBaker’s cyst

DIFFERENTIAL DIAGNOSIS OF ANKLE PAIN BASED ON ANATOMIC AREA

BOX 12-1

1. Observe the general function of the ankle.a. The patient’s stance.b. The patient’s ability to bear weight.c. The patient’s gait.

2. Perform passive stretching (stress testing) in eversionfor the deltoid ligament (medially) and in inversionfor the lateral ankle ligaments.

3. Measure the range of motion of the tibiotalar joint (ex-tension and flexion) and the subtalar joint (inversionand eversion) and compare with the unaffected side.

4. Palpate the posterior heel (Achilles tendon, calca-neus, and pre-Achilles bursa).

5. Palpate the plantar heel (plantar fascia, heel pad, andcalcaneus).

6. Perform a Tinel maneuver for tarsal tunnel syndrome.

SCREENING EXAMINATION OF THE ANKLE EMPHASIZING FUNCTION

BOX 12-2

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ABILITY TO BEAR WEIGHT

SUMMARY: The ability to walk easily depends on a flexible ankle joint; intact supporting ligaments;strong Achilles, posterior tibialis, and peroneus tendons; and normal lumbosacral nerve roots.

MANEUVER: The patient is asked to walk in theexam room. Symptoms can be enhanced by askingthe patient to toe-and-heel walk.

INTERPRETATION: This maneuver is used as ascreening for the more severe conditions (fractures,third-degree ligament sprains, acute gouty or septicarthritis, and Achilles tendon rupture)

FIGURE 12–1. Observe the patient’s ability to bear weight.

STANCE AND ANKLE ALIGNMENT WHENSTANDING

SUMMARY: Ankle alignment depends on a normaljoint, intact supporting ligaments, well-toned medialand lateral tendons, and tarsal bones free of de-generative arthritic change.

MANEUVER: The patient is asked to stand, placingan equal amount of weight on each side.

INTERPRETATION: Pes planus, pes cavus, and pesplano-valgus are readily identified by inspection of the foot and ankle. In addition, anterior jointswelling, dorsal edema, and color changes reflect-ing vascular insufficiency or reflex sympathetic dystrophy should be readily apparent by simple inspection of the dorsal and anterior aspects of the ankle.

FIGURE 12–2. Observe the patient’s stance and anklealignment when standing.


FLEXION AND EXTENSION

SUMMARY: The range of motion of the main anklejoint can be compromised by joint fluid, synovialthickening, bony osteophytes, bony fracture, an inflexible Achilles tendon, and tight calf muscles.Ankle effusion often is difficult to detect. Moderateto large effusions cause a bandlike swelling, sev-eral centimeters wide around the ankle, obliteratingthe normal bony contours of the malleoli.

MANEUVER: The range of motion, stiffness, andcrepitation are assessed by passive stretching of the ankle joint in flexion and extension.

INTERPRETATION: This maneuver is used primarilyto screen the main ankle joint for effusion, arthritis,and associated bony disorders.

FIGURE 12–3. Flexion and extension range of motion test-ing to assess the main ankle joint.

PASSIVE STRETCHING IN INVERSION AND EVERSION

SUMMARY: Ankle inversion and eversion occur atthe subtalar joint. Passive stretching assesses the integrity of the joint, its joint capsule, and the me-dial and lateral collateral ligaments that support the main ankle joint.

MANEUVER: Both ankles are passively stretched in inversion and eversion. The mobility, looseness,and sensitivity are compared side to side.

INTERPRETATION: Because subtalar arthritis is un-common outside the setting of rheumatoid arthritis,this maneuver is used to screen the collateral liga-ments of the main joint for integrity, looseness, oracute injury.

FIGURE 12–4. Passive stretching in inversion and ever-sion is used to assess the integrity of the lateral and medial collat-eral ligaments and the integrity of the subtalar joint.

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PALPATE THE POSTERIOR HEEL

SUMMARY: The three main structures of the poste-rior heel include the Achilles tendon, the pre-Achilles bursa located above the insertion of thetendon, and the retrocalcaneal bursa located in the space between the Achilles tendon and the posterior aspect of the talus.

MANEUVER: The entire length of the Achilles tendonis palpated from the calcaneus to the musculotendi-nous juncture, several inches above the insertion.The thickness and integrity of the tendon are noted.The pre-Achilles bursa is palpated at the insertionof the calcaneus. The retrocalcaneal bursa is pal-pated, with pressure directed against the posterioraspect of the talus.

INTERPRETATION: The pre-Achilles bursal swellingand tenderness is located at the superior aspect ofthe calcaneus. True Achilles tendonitis and ruptureoccur 3 to 4 cm above the insertion of the tendonon the calcaneus.

FIGURE 12–5. Palpate the posterior heel for Achilles ten-donitis, pre-Achilles bursal swelling, thickening for Achilles tendondisruption, retrocalcaneal bursitis, and os trigonum syndrome.

PALPATE THE PLANTAR HEEL

SUMMARY: The plantar aspect of the ankle consistsof the calcaneus, the specialized fat tissue protect-ing the calcaneus (the heel pad and its overlyingthick covering of epidermis), and the arch, consist-ing of the plantar fascia. The plantar fascia origi-nates from the undersurface of the calcaneus in the midline.

MANEUVER: The entire heel is palpated for localtenderness.

INTERPRETATION: Bony lesions of the calcaneusand the fat pad syndrome are characterized by dif-fuse tenderness. By contrast, plantar fasciitis is char-acterized by focal tenderness at the origin of thearch in the midline or slightly medial to the midline.

FIGURE 12–6. Palpate the plantar heel for local tenderness.


TRIAGE TO X-RAY For a patient who has a history oftrauma, is at risk for bony injury, or has sustained a typicalinversion ankle sprain type of injury:

• Order three views of the ankle for patients with a historyof inversion injuries, crush injuries, or direct blow to theankle (fibular, tibial, calcaneal, or talar dome fractures).

• Order three views of the ankle for patients with impairedambulation and a loss of range of motion of the true an-kle joint (posttraumatic osteoarthritis, rheumatoid arthri-tis, or the arthritis accompanying spondyloarthropathy).

• Order calcaneal views for patients with recurrent orchronic heel pain unresponsive to initial treatment (a cal-caneal stress fracture, large heel spur with plantar fasciitis,or pre-Achilles bursitis with large calcification).

• Order anteroposterior and inversion stress views of the an-kle in patients with persistent symptoms after injury to thesupporting ankle ligaments (instability of the ankle aftersevere ankle sprain).

• Order three views of the foot for patients with persistentlateral ankle pain and pain at the base of the fifthmetatarsal (peroneus avulsion fracture complicating anklesprain).

• Order a lateral ankle view for patients with persistent pos-terior ankle pain and limited plantar flexion (os trigonumsyndrome).

TRIAGE TO THE LAB For patients with acute pain, ex-quisite tenderness, inability to bear weight bear, and signs ofactive inflammation, order a complete blood cell count,uric acid, and erythrocyte sedimentation rate (gout or acutearthritis) and include blood cultures if the acute inflamma-

tory changes are accompanied by significant fever or con-current signs of infection elsewhere in the body (septicarthritis).

CONSIDER A BONE SCAN For patients with persis-tent but vague, poorly localized, or ill-defined ankle or heelpain (calcaneal stress fracture, reflex sympathetic dystrophy,osteomyelitis, or fracture accompanying severe anklesprain).

CONSIDER MRI For patients with chronic symptoms orsevere injuries to the Achilles (tendon rupture or chronicAchilles tendonitis) or patients with recurrent or chronicswelling of the ankle joint after injury (osteochondritis dis-secans of the talar dome accompanying severe ankle sprain).

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate ankle pain and stiffness, unre-stricted movement of the joint, normal alignment, and nor-mal gait:

• Limit walking, standing, impact, and repetitive movement.• Wear comfortable, high-top shoes with padded insoles or

padded insoles with arch supports.• Apply overlap taping of the ankle joint or strapping of the

plantar fascia.• Apply ice and elevate the foot four times a day.• Perform gentle daily passive stretching exercises in exten-

sion and flexion only.• Recommend an anti-inflammatory medication for 10 to


7 days (optional).


TINEL SIGN

SUMMARY: Pain that is referred to the ankle or footcan arise from compression of the posterior tibialnerve or from the lower lumbar roots. In either casethe patient describes a neurogenic type of pain(burning, tingling, or numbness) that is unassoci-ated with local ankle tenderness, impaired mobility,or a loss of ankle range of motion.

MANEUVER: The patient is asked to relax the foot.A Tinel tapping sign is performed just posterior tothe malleolus.

INTERPRETATION: A positive response reproducesthe patient’s pain. Typically the pain or paresthesiais referred down across the bottom of the foot or up the leg (retrograde conducted pain is almost al-ways caused by a compression neuropathy). Painthat is localized just to the area of tapping proba-bly is caused by posterior tibialis tendon irritationor injury.FIGURE 12–7. Perform a Tinel sign to assess for tarsal tunnel.

DETAILED EXAMINATION: SPECIFIC ANKLEDIAGNOSES

ANKLE SPRAIN The degree of local swelling and bruising, the patient’s ability to bear weight, the presence of bony tenderness

(the Ottawa criteria), and the mechanism of injury are used to as-sess the extent of ligament injury. The clinical challenge is to assesswhether the ligaments have been simply overstretched, partiallytorn, or completely ruptured and to determine the risk of accompa-nying bony fracture.

ANKLE 229

PASSIVE STRETCHING IN INVERSION

SUMMARY: The three lateral ligaments of the ankleare named for their bony attachments: anteriortalofibular, calcaneofibular, and posterior talofibu-lar. The anterior talofibular and calcaneofibular ligaments are the most susceptible to injury. Thereare three grades of ligament injuries: simple sprain(first degree), partially torn (second degree), andcompletely torn (third degree).

MANEUVER: The ankle is passively inverted, andthe patient’s pain tolerance, looseness, endpointstiffness, and guarding are noted.

ADDITIONAL SIGNS: Each ligament is palpated forlocal tenderness. Swelling and bruising over the lateral ankle are noted. Flexion and extension ofthe ankle are evaluated to assess concomitant ankleinjury and effusion. The distal fibula, the inferiormalleolus, and the base of fifth metatarsal are palpated for bony tenderness.

INTERPRETATION: The first-degree ankle sprain ischaracterized by mild restriction of ankle inversion,mild to moderate tenderness, mild swelling, and min-imal bruising. Partial tears are characterized bypoor tolerance of weight bearing, moderate tender-ness, moderate to severe guarding with inversion,and mild to moderate swelling with bruising. Third-degree ankle sprains are characterized by intoler-ance of weight bearing, severe tenderness, inversionguarding, dramatic swelling, and extensive bruising.

FIGURE 12–8. Passive stretching in inversion to assess thedegree of ligament injury.

LATERAL LIGAMENT TENDERNESS AND SWELLING

SUMMARY: The bleeding associated with the partialand complete tears of the lateral ligaments poolsbelow the lateral malleolus. The force of gravitycauses the blood to flow down the tissue planes ofthe ankle and foot to form the classic crescent sign.

MANEUVER: The lateral ankle and foot are inspectedfor bruising. The crescent sign is not painful. All ten-derness is located over the lateral ligaments.

ADDITIONAL SIGNS: See Figure 12–8.

INTERPRETATION: The crescent sign is a nonspecificsign of disrupted tissue. Calf muscle tears, plantaristendon rupture (at the knee), fracture of the tibia orankle, or second- and third-degree ankle sprain allcause significant bruising. However, the combina-tion of local tenderness over the lateral ligamentsand the crescent signs confirms a partial or com-plete ligament tear.

FIGURE 12–9. Lateral ligament tenderness and swellingsuggest higher-grade ligament injury.

INSTABILITY COMPLICATING ANKLE SPRAIN Ankleinstability is the most common complication of ankle sprain.Recurrent ankle sprain is exceedingly common after partial andcomplete tear of the supporting ligaments. Signs of instability areperformed after the acute symptoms of pain, swelling, and im-

paired weight bearing have resolved. The anterior and posteriordrawer signs, the passive range of motion of the ankle, and the ta-lar knock signs are performed to assess the degree of ligament lax-ity and ankle instability.


ANTERIOR DRAWER SIGN

SUMMARY: The patient has sustained a second- orthird-degree ankle sprain, and the acute symptomshave resolved. The anterior drawer sign assessesthe integrity and laxity of the anterior talofibular ligament.

MANEUVER: The examiner stabilizes the lower legby firmly grasping the tibia. With the other handplaced over the tarsal bones, the examiner appliesanterior force to the ankle joint. An abnormal re-sponse consists of an excessive anterior movementcompared with the opposite side. Pain or appre-hension that manifests during the maneuver stronglysuggests insufficiency of the anterior talofibular ligament.

ADDITIONAL SIGNS: The posterior drawer signmay be abnormal, suggesting insufficiency of theposterior talofibular ligament. If the interosseousmembrane between the tibia and fibula has beendisrupted, the talar knock sign will be abnormal(forced inversion and eversion causing the talus toknock into the tibia). If the calcaneofibular ligamenthas been torn, the affected ankle may have greaterdegrees of inversion movement. If any of the threelateral ligaments is completely torn, a concavitymay remain in its place.

INTERPRETATION: Patients with mild ankle instabilityoften comment, “My ankle doesn’t feel right.” Otherpatients simply describe multiple episodes of recur-rent ankle sprain. These patients rarely have abnor-mal instability signs. Only the severely traumatizedankle demonstrates an unequivocal abnormaldrawer sign, indicating either a complete anterioror posterior talofibular ligament rupture.

FIGURE 12–10. The anterior drawer sign to assess instabil-ity of the ankle.

ANKLE 231

STRESS VIEWS OF THE ANKLE

SUMMARY: Manually applied inversion and anteriorstress placed across the ankle are used to demon-strate the abnormal widening of the tibiotalar jointon plain x-rays of the ankle.

CASE: The patient is a 25-year-old avid basketballplayer who injured his ankle on many separate oc-casions. He has been unable to play because ofthe fear and apprehension his ankle “will give outonce again.” Examination disclosed a depressionover the calcaneofibular ligament and excessive inversion compared with the unaffected ankle.

DIAGNOSIS: Insufficiency of the calcaneofibular ligament.

INTERPRETATION: The lateral ankle joint demon-strated abnormal widening when inversion stresswas placed across the joint. A lateral view of theankle with anterior force placed across the anklewas normal; thus, the anterior talofibular ligamentwas intact.

FIGURE 12–11. Stress views of the ankle to confirm liga-ment instability.


ANTERIOR BALLOTTEMENT

SUMMARY: Effusion at the ankle must be distin-guished from simple edema and the swelling ofdorsotenosynovitis.

MANEUVER: The examiner places two fingers be-hind each malleolar process. Forward pressure isexerted on the back of the ankle to force any poste-rior fluid anteriorly. With thumbs on either side ofthe extensor tendons, the examiner uses back-and-forth compression to feel for excessive fluid accumu-lation. Normally the bony structure should be easilypalpated with the thumbs. A spongy feeling or asense of fullness is appreciated when excess fluid is present.

ADDITIONAL SIGNS: The range of motion in flexionand extension may be impaired with large or ex-tremely inflammatory effusions. Large effusions pres-ent with a bandlike swelling extending around thejoint, obliterating the bony prominences of themalleolar processes.

INTERPRETATION: Patients with simple edema andthe swelling of dorsotenosynovitis should maintainnormal and painless range of motion of the ankle.Patients with dorsotenosynovitis have pain with passive movement of the toes.

FIGURE 12–12. The anterior ballottement sign to assess forankle effusion.

INTRA-ARTICULAR ANESTHETIC BLOCK AND ASPIRATION

SUMMARY: Enter just medial to extensor hallucislongus (anteromedial approach) or just lateral to extensor digiti minimi (anterolateral approach).Because the lateral synovial cavity extends over a larger area, it is the preferred site of entry.


DEPTH: 1 to 11⁄4 inch through either the tibionavicu-lar ligament medially or the fibulonavicular liga-ment laterally.

VOLUME: 2 to 3 mL anesthetic, 1⁄2 mL K40, or both.

NOTE: If bone is encountered, withdraw backthrough the ligament, use skin traction to redirectthe needle either toward the midline or inferiorly,and advance again.

FIGURE 12–13. Intra-articular anesthetic block with orwithout aspiration of the joint.

ARTHRITIS OF THE ANKLE Rheumatoid arthritis is themost common cause of arthritis of the ankle. Osteoarthritis ismuch less common and occurs almost exclusively as a result of a previous injury (fracture or severe sprain). The diagnosis is

suggested by anterior joint line tenderness, impairment of flexionand extension, and impaired weight bearing. The diagnosis can beconfirmed by x-ray, intra-articular anesthetic block, or joint fluidanalysis.

SUBTALAR ARTHRITIS Arthritis affecting the subtalar jointis uncommon. Rheumatoid arthritis and previous fracture or in-jury to the talus are the most common causes. X-ray interpretationis difficult. Confirmation of this diagnosis requires local anestheticblock.

ANKLE 233

INTRA-ARTICULAR ANESTHETIC BLOCK

SUMMARY: The subtalar joint can be injected froma lateral or medial approach. Laterally, the jointline is located 1 cm below the most inferior point of the lateral malleolus. The injection is placed flushagainst the talus or calcaneus, adjacent to the jointline.



VOLUME: 1 to 2 mL anesthetic, 1⁄2 mL D80, or both.

NOTE: Because the peroneus tendon follows acourse very close to the lateral malleolus, the pointof entry should err more toward the heel than themalleolus. To ensure the safest possible injection,the bevel of the needle should be kept parallel tothe fibers of the tendon.

FIGURE 12–15. Intra-articular anesthetic block to confirmsubtalar arthritis.

PASSIVE INVERSION AND EVERSION

SUMMARY: The subtalar joint allows the ankle to invert and evert. Progressive arthritis leads to pro-gressive loss of inversion and eversion.

MANEUVER: The examiner stabilizes the lower legby firmly grasping the tibia. With the oppositehand the examiner passively inverts and everts theankle and foot while preventing flexion and exten-sion of the main ankle joint. The range of motion is compared side to side.

ADDITIONAL SIGNS: Tenderness may be presentwhen firm pressure is applied just under the malleo-lar processes.

INTERPRETATION: In the absence of trauma (acutefracture, ankle sprain, or injury to the supportingperoneus and posterior tibialis tendons), loss of in-version and eversion is attributed to arthritis of thesubtalar joint.

FIGURE 12–14. Perform passive inversion and eversion toassess the integrity of the subtalar joint.

ACHILLES TENDONITIS AND RUPTURE Achilles ten-donitis is characterized by tenderness, swelling, and thickening atthe musculotendinous junction, located 2 to 3 inches above the in-sertion of the tendon on the calcaneus. The pain is characteristi-

cally reproduced by passively performed dorsiflexion and activelyresisted plantarflexion. Complete tendon rupture is characterizedby a loss of active plantarflexion, a palpable defect 2 to 3 inchesabove the calcaneal insertion, and varying degrees of bruising.


ACHILLES TENDON

SUMMARY: The Achilles tendon is susceptible to in-jury, irritation, inflammation, and tendon rupture.Risk factors include tight, inflexible calf muscles,plantar fasciitis, sports involving repetitive jumping,an improperly placed corticosteroid injection, andthe rare case of chronic fluoroquinolone exposure.

MANEUVER: The Achilles tendon is palpated for ten-derness, swelling, thickening, or disruption along itslength from the calcaneus to the musculotendinousjuncture.

ADDITIONAL SIGNS: The pain of active tendonitiscan be reproduced by passively dorsiflexing the an-kle, stretching the tendon, or by isometrically resist-ing plantarflexion. Patients with true tendon rupturecannot actively plantarflex the ankle. If tendon rup-ture has occurred, a defect in the tendon is palpa-ble at that site.

INTERPRETATION: Acute Achilles tendonitis is char-acterized by localized swelling, exquisite tender-ness, and mild thickening. Chronic Achilles ten-donitis is characterized by minimal tenderness and thickening. Tendon rupture usually follows atraumatic injury, followed by immediate inability toplantarflex the ankle and the palpable defect in thetendon.

FIGURE 12–16. Palpate the Achilles tendon for swelling,thickening, or disruption.

MRI

SUMMARY: All cases of Achilles tendonitis are char-acterized pathologically by microtearing of the ten-don with secondary inflammation. With further in-jury the weakened tendon can proceed to completetear.

CASE: This 35-year-old weekend baseball playerhad a violent slide into second base. All of hisbody weight struck the base with his leg in the ex-tended position. Symptoms waxed and waned overthe next several weeks, with progressive posteriorheel pain and tendon swelling. On exam the ten-don was 21⁄2 times normal width.

CASE: Acute Achilles tendonitis with mucinoid de-generative swelling in the center of the tendon.

INTERPRETATION: MRI is the test of choice to distin-guish Achilles tendonitis from partial tears and com-plete rupture.

FIGURE 12–17. MRI to assess Achilles tendon inflammation,partial tear, or complete tendon rupture.

PRE-ACHILLES BURSITIS Pre-Achilles bursitis (the “pumpbump”) is an inflammation of the bursal sac located at theAchilles tendon insertion on the calcaneus. It develops as a reac-tion to the pressure and friction created by tight-fitting shoes. Thediagnosis is based on the specific site of local tenderness and

swelling over the calcaneus and confirmed by local anestheticblock. Anesthetic is injected in the subcutaneous tissue, 1/4 inch be-low the skin, centered over the calcaneus, and just above the fibersof the Achilles tendon.

ANKLE 235

PALPATE THE PRE-ACHILLES BURSA

SUMMARY: The pre-Achilles bursa provides lubrica-tion between the skin and the insertion of theAchilles tendon. It is a pressure-sensitive sac aggra-vated by tight-fitting shoes and repetitive flexionand extension of the ankle.

MANEUVER: The quarter-sized bursa is located inthe midline directly over the center of the attachmentof the Achilles tendon to the superior calcaneus.Tenderness, swelling, and thickening are noted.

ADDITIONAL SIGNS: The bursa should be soft andcompressible unless chronic thickening or calcifica-tion has developed. Haglund’s deformity is a largecalcification arising from the superior calcaneus.

INTERPRETATION: Pre-Achilles bursitis often is con-fused with Achilles tendonitis. The two conditions arenot related. Bursal inflammation always occurs at theinsertion of the tendon, whereas true Achilles ten-donitis occurs several centimeters above the insertion.

FIGURE 12–18. Palpate the pre-Achilles bursa for swellingand bony thickening.


SUMMARY: A presumptive diagnosis of pre-Achillesbursitis can be made based solely on the typicalswelling and tenderness located directly over thesuperior calcaneus. Local anesthetic block may be necessary in the uncommon event that bursitisoccurs concomitantly with Achilles tendonitis. Enterover the posterior–superior aspect of the calcaneus,directly in the midline.



VOLUME: 1⁄2 to 1 mL anesthetic, 1⁄2 mL D80, orboth.

NOTE: The injection should be superficial to the ten-don; high pressure during injection suggests an in-tratendinous position.

FIGURE 12–19. Local anesthetic block to confirm pre-Achilles bursitis.

RETROCALCANEAL BURSITIS Retrocalcaneal bursitis is anuncommon problem. Patients complain of posterior ankle painand swelling located between the Achilles tendon and the posteriorof the talus. The normal concavity behind the ankle is filled in

with soft tissue swelling. The diagnosis is suggested by these subjec-tive changes and confirmed with local anesthetic placed just poste-rior to the talus.



SUMMARY: Local anesthetic block is used to distin-guish the local bursal irritation from simple edema,the swelling that accompanies ankle arthritis, and the pain caused by os trigonum syndrome. The safest point of entry is on the lateral side of theAchilles tendon, 1 inch above the calcaneus. Thisavoids the neurovascular bundle containing the posterior tibialis artery, vein, and nerve.


DEPTH: 3⁄4 to 1 inch (1⁄2 inch posterior to the tibiaand talus).

VOLUME: 1⁄2 mL anesthetic, 1⁄2 mL D80, or both.

NOTE: Place the medication adjacent to the talusrather than the Achilles tendon.

FIGURE 12–21. Local anesthetic block is used to confirmretrocalcaneal bursitis.

LOCAL TENDERNESS OF THERETROCALCANEAL SPACE

SUMMARY: The retrocalcaneal bursa is located inthe soft tissue space between the Achilles tendonand the posterior aspect of the ankle. Its function isto lubricate the posterior ankle structures in extremeplantarflexion.

MANEUVER: The posterior aspect of the ankle is in-spected for swelling and compared with the oppo-site side. Local tenderness is palpated using two fingers compressing the soft tissues in the space between the Achilles tendon and the talus.

ADDITIONAL SIGNS: The patient’s pain should bereproduced by passive plantarflexion of the ankle,compressing the bursa between the Achilles tendon,the calcaneus, and the talus.

INTERPRETATION: Simple edema should not bepainful to direct palpation of the compressive effects of forced plantarflexion. Swelling largeenough to fill in the bony contours of the posteriorankle should be present anteriorly and reduce theoverall range of motion of the ankle.

FIGURE 12–20. Local tenderness of the retrocalcanealspace detected by manual compression of the soft tissue betweenthe posterior ankle and the Achilles tendon.

OS TRIGONOM SYNDROME Os trigonum syndrome is anuncommon problem. The patient describes posterior ankle painthat is aggravated by movement of the big toe. The diagnosis de-

pends on x-ray confirmation of a well-circumscribed accessorybone at the junction of the flexor hallucis longus tendon and theposterior aspect of the talus.

ANKLE 237

OS TRIGONUM TENDERNESS

SUMMARY: Os trigonum syndrome consists of themechanical sequelae of the presence of the acces-sory bone located just posterior to the talus. Thebone is in intimate contact with the flexor hallucislongus tendon. Tenosynography of the flexor hallu-cis tendon shows a constriction of the sheath at thelevel of the accessory bone.

MANEUVER: Tenderness is elicited by placing firmpressure in the space between the Achilles tendonand the posterior aspect of the talus. The pressureis directed against the talus.

ADDITIONAL SIGNS: Resisting flexion of the greattoe should reproduce the posterior ankle pain. Fullplantarflexion may be impaired with the larger ac-cessory bones. Otherwise the range of motion ofthe ankle usually is well maintained.

INTERPRETATION: The symptoms of os trigonum syndrome overlap with those of retrocalcaneal bur-sitis. The tenderness is in the same exact location.However, bursitis typically has a greater degree ofsoft tissue swelling. A lateral x-ray view of the anklewill readily distinguish the two conditions.

FIGURE 12–22. Os trigonum tenderness over the posterioraspect of the talus in the midline.

LATERAL X-RAY VIEW OF THE ANKLE

SUMMARY: Patients with a history of trauma to theankle, especially in severe plantarflexion, shouldundergo plain x-rays or CT scanning to rule outfracture of the posterior process of the talus. The os trigonum syndrome cannot be made untilfracture has been excluded by radiography.

CASE: Os trigonum syndrome.

INTERPRETATION: Fracture of the talus is character-ized by ill-defined and irregular bony borders. Onthe other hand, the os trigonum bone should bespherical with well-demarcated borders. The defini-tive treatment for os trigonum syndrome is resectionof the accessory bone.

FIGURE 12–23. Lateral x-ray view of the ankle readilyidentifies the accessory bone.

PLANTAR FASCIITIS The diagnosis of plantar fasciitis, an in-flammation of the longitudinal or “arch” ligament of the foot, re-quires midline tenderness localized to a dime-sized area at the cal-caneal attachment. Severe cases are characterized by calcaneal

bony irritation (compression of the calcaneus from side to side)and pain aggravated by forced ankle dorsiflexion. Gastrocnemiusmuscle tightness, pes planus, pes cavus, ankle pronation, and obe-sity are predisposing factors.



SUMMARY: When plantar fascial signs accompanypossible stress fracture of the calcaneus or signs ofthe fat pad syndrome, local anesthetic block is usedto distinguish the three conditions. The needle ispassed through the plantar surface in the midline,approximately 3⁄4 inch distal to the origin of theplantar fascia.


DEPTH: 1 to 11⁄2 inch.

VOLUME: 1 to 2 mL anesthetic, 1 mL D80, or both.

NOTE: The injection must be at a depth greater than1 inch to avoid injecting steroid in the specializedfat of the heel pad.

FIGURE 12–25. Local anesthetic block to confirm plantarfasciitis.

PLANTAR FASCIA

SUMMARY: The plantar fascia originates from thecalcaneus and forms the arch of the foot. The fibersfan out to attach to four of the metatarsals.

MANEUVER: The patient lies prone on the examtable. The origin of the plantar fascia is palpated atthe base of the arch in the midline. If tenderness isnot obtained directly in the midline, the examinerpalpates the medial side of the origin.

ADDITIONAL SIGNS: Side-to-side compression ofthe calcaneus is painful in moderate to severecases. Severe cases may be aggravated by forceddorsiflexion of the ankle, stretching the fascia.Uncommonly, pressure over the origin can causeswelling along the medial aspect of the heel. Side-to-side compression of the fat pad is not painful.

INTERPRETATION: Plantar fasciitis has a characteris-tic focal tenderness. Diffuse heel tenderness is mostoften caused by heel pad syndrome. Patients withcalcaneal stress fractures or Sever’s epiphysitishave focal plantar surface tenderness. However,these patients characteristically have greater bonypain with side-to-side compression than direct ten-derness from palpation.

FIGURE 12–24. Palpate the origin of the plantar fascia for lo-cal tenderness.

HEEL PAD SYNDROME Patients with heel pad syndrome, atrauma-induced irritation of the specialized fat of the heel, presentwith symptoms identical to those of plantar fasciitis. However, theexam of the heel is distinctively different. The entire heel is tender

to palpation. The pain is readily reproduced by side-to side-compression of the fat pad. Side-to-side compression of the calca-neus is not painful; the bone is unaffected.

ANKLE 239

COMPRESSION OF THE CALCANEAL HEEL PAD

SUMMARY: The calcaneus is protected by special-ized fat that is compartmentalized by thick fascialtissue. Traumatic injuries can break down the nor-mal fascial septa, leading to a diffuse pain and tenderness over the entire heel. This injury often iscalled the stone bruise of the heel. Simple protec-tion with a padded insole or heel cup should re-solve the irritation within 2 to 3 weeks.

MANEUVER: The heel pad is compressed from sideto side, recreating the patient’s pain.

ADDITIONAL SIGNS: The entire heel is tender.Compression of the calcaneus does not elicit pain.The origin of the plantar fascia is no more tenderthan the rest of the heel.

INTERPRETATION: The combination of diffuse heeltenderness and pain reproduced by side-to-sidecompression of the heel pad confirms the diagnosis.

FIGURE 12–26. Compression of the calcaneal heel padfor tenderness.

HEEL PAD SYNDROME

SUMMARY: Simple padding used continuouslyover 2 weeks should resolve an uncomplicatedcase of heel pad syndrome. Calcaneal stress frac-ture and plantar fasciitis rarely resolve in thisshort time period.

CASE: The patient stumbled while walking down aflight of stairs. The patient missed the last step andcame down hard on the right heel. The heel wasdiffusely tender. The pain was reproduced by side-to-side compression of the heel pad. Within 2weeks the condition resolved with heel pads.

DIAGNOSIS: Heel pad syndrome.

FIGURE 12–27. The diagnosis of heel pad syndrome ismade when symptoms improve after 2 weeks with simplepadding.

CALCANEAL STRESS FRACTURE Microfracturing of theposterior aspect of the calcaneus is an uncommon condition, seenalmost exclusively in long-distance runners or patients with severeosteopenia. The diagnosis should be suspected whenever the side-to-

side compression of the calcaneus elicits a greater degree of painthan direct palpation of the heel, just the opposite of the findings of plantar fasciitis. The diagnosis is confirmed by bone scanning.


SERIAL X-RAYS OR NUCLEAR BONE SCAN

SUMMARY: The proximal third of the body of thecalcaneus is most susceptible to the repeatedtrauma of running and jumping. Stress fractures canoccur in the nonathlete with severe osteopenia.

CASE: This 54-year-old woman with chronic renalfailure on dialysis developed bilateral heel painthat progressed over several weeks. Initial x-rayswere normal. Her exam demonstrated pain whenthe calcaneus was compressed from side to side.The patient had secondary hyperparathyroidism.

DIAGNOSIS: Calcaneal stress fracture. Repeat x-rays demonstrated a band of sclerotic bone overthe proximal third of the calcaneus. The entire cal-caneus was active on nuclear bone scan.

INTERPRETATION: Initial plain x-rays are notoriouslyinaccurate in the first 2 to 3 weeks. The diagnosiscan be confirmed by the demonstration of the typi-cal sclerotic bone (osteoblastic activity of a healingfracture) on serial ankle x-rays. Nuclear bone scan-ning has the advantage of confirming the diagnosisin the first few weeks.

FIGURE 12–29. Serial x-rays or nuclear bone scan toconfirm calcaneal stress fracture.

CALCANEAL COMPRESSION

SUMMARY: Calcaneal stress fractures are uncom-mon. Tibial and metatarsal stress fractures are muchmore common. However, when athletes (runners es-pecially) present with diffuse pain and tendernessover the heel and the diagnosis of plantar fasciitisis not likely, evaluation for calcaneal stress fractureshould be considered.

MANEUVER: The hands are cupped over the sidesof the calcaneus bone. With the fingers locked inplace, the sides of the calcaneus are compressedbetween the heels of the palms. Bony lesions, frac-tures, and stress fractures typically are more sensi-tive to compression than simple palpation of theplantar aspect of the heel.

ADDITIONAL SIGNS: The bottom of the heel usuallyis diffusely tender. The origin of the plantar fascia isno more sensitive than the rest of the heel. Squeez-ing the fat pad from side to side typically does notelicit pain.

INTERPRETATION: In the absence of direct trauma tothe heel, focal compression tenderness over the cal-caneus strongly indicates a stress fracture.

FIGURE 12–28. Perform a calcaneal compression sign to as-sess the integrity of the calcaneus.

POSTERIOR TIBIAL TENOSYNOVITIS The posterior tibialtendon is susceptible to friction as it passes under the medial malle-olus bone. Inflammation of this tendon and its overlying sheath issuggested by a history of medial ankle pain and an exam demon-

strating medial ankle tenderness that is reproduced by resisted in-version and plantarflexion. However, a definitive diagnosis re-quires local anesthetic block placed along the tendon, just inferiorto the tip of the medial malleolus.

ANKLE 241

ISOMETRIC RESISTANCE OF INVERSION

SUMMARY: The posterior tibialis tendon is locatedjust under the medial malleolus of the ankle and attaches distally to the navicular, talus, three cuneiforms, and three middle metatarsals.Contraction of the muscle causes the ankle to plan-tarflex, adducts and inverts the foot, and supportsthe arch.

MANEUVER: The patient is asked to maintain theankle in neutral position, avoiding stretching thesupporting ligaments and joint capsule during the maneuver. Then the patient is asked to invertthe foot against the resistance of the examiner’shand. The patient’s pain at the malleolus should be reproduced by the maneuver.

ADDITIONAL SIGNS: Isometric resistance of plan-tarflexion may be equally painful. Maximum tender-ness is present over the tenosynovial sheath locatedjust below the malleolus. Range of motion of the an-kle should be normal.

INTERPRETATION: The local tenderness of medialcollateral ligament injuries, bony lesions of thetalus, and tibial bony fractures overlaps with the local tenderness of posterior tibialis tenosynovitis.However, only the tenosynovitis is aggravated byisometric testing of the tendon in inversion andplantarflexion.

FIGURE 12–30. Isometric resistance of inversion to assessposterior tibial tenosynovitis.


SUMMARY: Enter just below the posterior edge ofmedial malleolus. The layers down to the posteriortibialis tendon include skin, subcutaneous fat, reti-nacular fascia, tenosynovial sheath, tendon, andtalus bone.




NOTE: Keep the bevel of the needle parallel to thetendon, allowing the fibers to separate and avoid-ing cutting through the fibers. Use the least amountof anesthetic in the superficial layers, injecting justenough anesthetic for comfort. Inject the majority ofthe anesthetic at the level of the tendon or talus inorder to maximize the local anesthetic block.

FIGURE 12–31. Local anesthetic block is needed to confirmthe diagnosis of posterior tibialis tendonitis.

PERONEUS TENOSYNOVITIS Peroneus tenosynovitis, aninflammation of the tendon as it passes under the lateral malleolusbone, is an uncommon complication of ankle sprain. The diagno-sis is suggested by persistent lateral ankle tenderness that is consis-

tently aggravated by isometrically resisted eversion and plan-tarflexion. Because the symptoms and signs closely mimic those of ankle sprain, the diagnosis requires local anesthetic block placedjust inferior to the tip of the lateral malleolus.



SUMMARY: Enter just below the posterior edge oflateral malleolus. The layers down to the peroneustendon include skin, subcutaneous fat, retinacularfascia, tenosynovial sheath, tendon, and talusbone.




NOTE: Keep the bevel of the needle parallel to thetendon to avoid cutting the fibers of the tendon.Use the least amount of anesthetic in the superficiallayers, injecting just enough anesthesia for comfort.Inject the majority of the anesthetic at the level ofthe tendon or talus in order to maximize the localanesthetic block.

FIGURE 12–33. Local anesthetic block to confirm peroneustenosynovitis.

ISOMETRIC RESISTANCE OF EVERSION

SUMMARY: The peroneus tendons evert the foot and plantarflex the ankle. The peroneus tertius and brevis tendons attach to the base of the fifthmetatarsal. The peroneus longus attaches to the first cuneiform and the first metatarsal.

MANEUVER: The patient is asked to maintain theankle in neutral position, avoiding stretching the supporting ligaments and joint capsule duringthe maneuver. Then the patient is asked to evert the foot against the resistance of the examiner’shand. The patient’s pain at the malleolus should be reproduced by the maneuver.

ADDITIONAL SIGNS: Isometric resistance of plan-tarflexion may be equally painful. Maximum tender-ness is present over the tenosynovial sheath locatedjust below the malleolus. Range of motion of the ankle should be normal.

INTERPRETATION: The local tenderness of lateral liga-ment injuries, bony lesions of the talus, and fibularbony fractures overlaps with the local tenderness ofperoneus tenosynovitis. However, only the tenosynovi-tis is aggravated by isometric testing of the tendon.FIGURE 12–32. Isometric resistance of eversion to assess

for peroneus tenosynovitis.

TARSAL TUNNEL SYNDROME Tarsal tunnel syndrome is acompression neuropathy of the posterior tibial nerve. The diagno-sis is strongly suggested if the patient’s electric-like pain, either upthe leg or into the plantar aspect of the foot, is reproduced by the

Tinel sign, tapping just under the medial malleolus bone. Severeankle pronation, previous ankle fracture, and severe ankle synovi-tis from inflammatory arthritis are predisposing factors.

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TINEL SIGN

SUMMARY: The posterior tibial nerve coursesaround the medial malleolus, branches to form themedial and lateral plantar nerves, and providessensation to the plantar surface of the foot.

MANEUVER: The medial malleolus is identified andthe inferior point is marked. Using the index finger,vigorous tapping is performed just under the medialmalleolus.

ADDITIONAL SIGNS: Because tarsal tunnel syn-drome results from severe pronation, previous anklefracture, or advanced arthritis of the ankle, theexam is completed with evaluation of stance, rangeof motion of the ankle joint, and radiographic stud-ies to assess the integrity of the underlying tarsalbones.

INTERPRETATION: The Tinel sign is considered posi-tive if the patient’s plantar symptoms or pain travel-ing in a retrograde direction up the leg are repro-duced. Tenderness and pain localized to the areaaround the medial malleolus arise from the poste-rior tibial tendon or the underlying tarsal bones.

FIGURE 12–34. A positive Tinel sign reproducing the patient’spain strongly suggests tarsal tunnel.

NERVE CONDUCTION VELOCITY TESTING

SUMMARY: The manifestation of tarsal tunnel syn-drome includes paresthesia and hypesthesia on the plantar surface of the foot or pain that travels in a retrograde direction up the leg. Weakness ofthe intrinsic muscles of the foot is rarely affected.The definitive diagnosis depends on demonstrationof nerve transmission slowing across the ankle byelectrophysiologic testing.

FIGURE 12–35. Nerve conduction velocity testing fortarsal tunnel syndrome.



Severe pain with ankle passive inversion #1: Severe ankle sprain, Examination, ankle series x-rayfibular fracture, interosseous membrane disruption, osteochondritis dissecans

Local tenderness over the affected ligament

Dramatic swelling over the lateral ankle

Inability to bear weight or walk naturally

Exaggerated movement Instability of the ankle Examination, stress views of the ankle

�Anterior or posterior drawer sign

�Talar knock sign

Inability to heel or toe walk

Pain, swelling, and decreased range of motion of Ankle arthritis, hemarthrosis, Aspiration of the cell count, differential, crystals, Gram the tibiotalar joint osteochondritis dissecans stain, culture, and ankle series x-ray

Anterior joint line tenderness

Decreased flexion and extension

Inability to bear weight or walk naturally

Pain, swelling, and decreased range of motion Subtalar arthritis Intra-articular anesthetic blockof the subtalar joint

Decreased inversion and eversion

Tenderness below the medial and lateral malleoli

Tender and enlarged Achilles tendon 2 inches Achilles tendonitis Examination, MRI of the ankle (optional)above the calcaneal insertion

Pain aggravated by resisted plantarflexion

Pain aggravated by passive dorsiflexion

Tender Achilles tendon and a defect 2 inches Achilles tendon rupture MRI of the ankle (optional)above the calcaneal insertion

Total loss of plantarflexion

Pain aggravated by passive dorsiflexion

Tender and swollen Achilles tendon insertion Pre-Achilles bursitis Anesthetic block in the bursaon the calcaneus

Retrocalcaneal swelling and local tenderness Retrocalcaneal bursitis Anesthetic block placed just posterior to the talus

Pain aggravated by passive plantarflexion compressing the bursa

Retrocalcaneal local tenderness Os trigonum syndrome Lateral x-ray of the ankle

Pain aggravated by passive extension of the big toe

Pain aggravated by isometric flexion of the big toe

Tenderness at the origin of the plantar fascia Plantar fasciitis Anesthetic block placed at the origin

Mild pain with calcaneal compression applied medially to laterally

Mild pain with forced dorsiflexion of the foot

Tenderness over the entire plantar heel Heel pad syndrome Examination, resolution in 2 weeks with simple padding with heel cups

Pain aggravated by compression of the fat pad

Severe pain with compression of the calcaneus Calcaneal stress fracture Bone scan or serial x-rays of the ankle

History of running or heavy exercise

Medial ankle pain aggravated by resisted inversion Posterior tibialis tendonitis Anesthetic block in the tenosynovial sheath

Tenderness and swelling just inferior to the medial malleolus

Pain aggravated by passive eversion

Lateral ankle pain aggravated by resisted eversion Peroneus tendonitis Anesthetic block in the tenosynovial sheath

Tenderness and swelling just inferior to the lateral malleolus

Pain aggravated by passive inversion

�Tinel sign over the medial ankle Tarsal tunnel syndrome Nerve conduction velocity testing

Subjective numbness over the plantar aspect of the foot

COMMON ANKLE FRACTURESSUMMARY

Fractures of the ankle probably are the most difficult of allfractures to manage, in part because of the complexity ofthe ankle joint but also because of the variety of fracturesthat can occur. Various combinations of injuries to liga-ments, the interosseous membrane, and surrounding boneare possible. Classification is based on the injury pattern,the affected bones and ligaments, the degree of fragment

displacement, and the degree of incongruity of the articularsurface. The Henderson system identifies malleolar, bi-malleolar, and trimalleolar fractures. Lauge–Hansen classifiesaccording to injury forces; and the supination–adduction in-jury pattern corresponds to the classic turned-in anklesprain. Danis–Weber classifies the fractures according to thelocation of the fibular fracture relative to the syndesmosis,which correlates well with fracture instability.

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FIBULAR AVULSION FRACTURE

SUMMARY: Severe inversion injuries of the anklecan cause the avulsion of a fleck of bone from themost distal portion of the fibula. The calcaneofibu-lar ligament detaches a small portion of cortexwhen the ankle is turned in.

IMMOBILIZATION: A short leg walking cast is thetreatment of choice. Immobilization should be con-tinued for 3 to 4 weeks to allow the ligament toreattach securely to the fibula.

SURGICAL REFERRAL: Unnecessary.

PROGNOSIS: Excellent unless accompanied by achondral fracture, incomplete healing of the lateralligaments, osteochondritis dissecans, or peroneustendon injury.

FIGURE 12–37. Fibular avulsion fracture associated withsevere ankle sprains.

ANKLE FRACTURE ALIGNMENT

SUMMARY: The primary care physician’s goal is toaccurately diagnose the extent of the injury by as-sessing the severity of the injury, the radiographicabnormalities, and the stability of the fracture andjoint. The posteroanterior, lateral, and mortise x-rays are used to define the number and locationsof the fractures. Measurements of the tibiofibularline, talocrural angle, talar tilt, and medial clearspace from these views are used to determine fracture stability and displacement. Angle measure-ments on stress views of the ankle are used to de-termine ligamentous injuries. CT scans are used todefine complex fracture patterns.

FIGURE 12–36. Ankle fracture alignment and stability aremeasured using the mortise view.

DISPLACED FIBULAR FRACTURE

SUMMARY: Most fractures at the syndesmosis, allfractures above the syndesmosis, and fractures withsignificant displacement (radiographically, by linemeasurement or stress views) should be referred tothe fracture specialist. Note the abnormal wideningof the talofibular space.

IMMOBILIZATION: Initially, the patient is placed ina Jones dressing, given crutches, and instructed toavoid weight bearing.

SURGICAL REFERRAL: Surgical referral is necessaryfor definitive open reduction and internal fixation.

PROGNOSIS: The prognosis depends on the degreeof reduction, the age of the patient, and the under-lying associated injuries to the ligaments, tendons,and articular cartilage.

FIGURE 12–39. Displaced fibular fracture warrants surgicalreferral.


NONDISPLACED FIBULAR FRACTURE

SUMMARY: Nondisplaced single malleolar fracturesand stable bimalleolar fractures can be treated non-operatively.

IMMOBILIZATION: Initially, a Jones compressiondressing with plaster splint reinforcement is used un-til swelling begins to resolve. Subsequently, a shortleg walking cast, fracture brace, or walking boot isprescribed. Weight bearing is limited until fracturehealing is documented.

SURGICAL REFERRAL: Surgical intervention is notnecessary.

PROGNOSIS: Excellent unless accompanied by achondral fracture, incomplete healing of the lateralligaments, osteochondritis dissecans, or peroneustendon injury.

FIGURE 12–38. Nondisplaced fibular fracture treated witha short leg walking cast.

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DISPLACED TIBIAL FRACTURE

SUMMARY: This displaced tibial malleolar fracture isunstable and has a unacceptable risk of posttrau-matic osteoarthritis of the ankle. Note the abnormalwidening of the tibiotalar space and the widening ofthe syndesmosis (interosseous membrane disruption).

IMMOBILIZATION: The patient should be placed ina Jones dressing, given crutches, and instructed toavoid weight bearing until seen by the fracture specialist.

SURGICAL REFERRAL: Surgical referral is necessaryfor definitive open reduction and internal fixation.

PROGNOSIS: The prognosis depends on the degreeof reduction, the age of the patient, and the under-lying associated injuries to the ligaments, tendons,and articular cartilage.

FIGURE 12–40. Displaced tibial fracture warrants surgicalreferral.

FRACTURE OF THE TALUS

SUMMARY: Inversion injury with extreme equinus orextreme dorsiflexion positioning can cause a injuryto the talus, including fracture of the lateral processof the talus, fracture of the posterior process of thetalus, and osteochondritis dissecans (depictedhere). The fracture of the posterior process must bedistinguished from the os trigonum, an accessorybone that is located posterior to the talus. A mortisview or posteroanterior tomograms usually are nec-essary to demonstrate the fracture line.

IMMOBILIZATION: Small and minimally displacedfragments can be treated with a compressive dress-ing or a short leg walking cast for 4 to 6 weeks.

SURGICAL REFERRAL: If the fragments are large, sur-gical referral for internal fixation is needed.

PROGNOSIS: These injuries carry a significant riskof posttraumatic arthritis.

FIGURE 12–41. Fracture of the talus accompanying severeankle sprain.


CALCANEAL FRACTURES

SUMMARY: The calcaneus is the tarsal bone that ismost commonly fractured. Most fractures result fromvertical falls and twisting injuries. Fractures are classi-fied as extra-articular or intra-articular. Extra-articularfractures are further subdivided into anterior, tuberos-ity, medial process, sustentacular, and body fractures(depicted here). Radiographically, posteroanterior,lateral, axial-calcaneal, and oblique views are com-bined with CT scans to define the location and intra-articular extension of the fragments.

IMMOBILIZATION: Most extra-articular fractures canbe treated nonoperatively. Initially, Jones compres-sion dressing is applied for 2 to 3 days and com-bined with 5 to 6 days of strict bed rest with leg el-evation. If pain and swelling have been controlled,a short leg walking cast is applied. Ambulation isrestricted to non–weight-bearing crutches until unionis definitely seen on repeat x-rays (typically severalweeks). Subsequently, weight bearing is increasedthrough partial to full weight bearing, as tolerated.

SURGICAL REFERRAL: Surgical referral is indicatedfor nonunion of the anterior process fracture, fordisplaced posterior process fractures (to restore theintegrity of the Achilles tendon), and for all intra-articular fractures.

PROGNOSIS: Intra-articular fractures heal unpre-dictably. The clinician must apprise the patient ofthe potential of long-term complications, includingsubtalar joint pain, subtalar posttraumatic arthritis,peroneus tendinitis, bone spur formation, calca-neocuboid osteoarthritis, or entrapment of the me-dial and lateral plantar nerves.

FIGURE 12–43. Calcaneal fractures, extra-articular and intra-articular.

AVULSION FRACTURE OF THE BASE OF THE FIFTH METATARSAL

SUMMARY: Inversion injury with rotation can causeexcessive pressure on the peroneus brevis tendonand result in an avulsion fracture of the base of thefifth metatarsal.

IMMOBILIZATION: Small and minimally displacedfragments can be treated with a short leg walkingcast for 4 to 6 weeks.

SURGICAL REFERRAL: Surgical referral is unnecessary.

PROGNOSIS: The prognosis is excellent unless thefracture is accompanied by a chondral fracture, in-complete healing of the lateral ligaments, or osteo-chondritis dissecans.

FIGURE 12–42. Avulsion fracture of the base of the fifthmetatarsal.

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FRACTURES OF THE TALUS

SUMMARY: The incidence of talus fractures is sec-ond only to that of calcaneal fractures. Classically,these are the result of hyperdorsiflexion injuries(e.g., from hitting the brakes). Fractures are classi-fied as chips, avulsions, or nondisplaced or dis-placed neck fractures.

IMMOBILIZATION: Nondisplaced fractures respondto 8 to 12 weeks of immobilization with a shortleg walking cast in a slightly equinus position forthe first month, followed by 1 to 2 months in theneutral position. As soon as union is documentedon repeat x-rays, range of motion exercises canbe started.

SURGICAL REFERRAL: Surgical referral is advisablefor the displaced neck fracture (depicted here),which is often accompanied by subtalar joint dislo-cation, because a favorable outcome demands aperfect reduction of the articular cartilage.

PROGNOSIS: Unfortunately, despite perfect reduc-tion, healing can be complicated by avascularnecrosis of the body in as many as 50% of cases.

FIGURE 12–44. Fractures of the talus.

• A patient with a first-degree ankle sprain that does notheal within 3 weeks or a second- or third-degree sprainthat does not heal within 6 weeks should be evaluatedfor potential ankle sprain complications including in-stability due to poor healing, avulsion of the peroneustendon, avulsion of the calcaneofibular ligament, in-terosseous membrane rupture, talar dome osteochon-dritis dissecans, or chondral fracture of the talus with as-sociated ankle effusion.

• The anterior talofibular ligament is most commonly in-jured by the inversion injuries that occur with running.

CLINICAL PEARLS

• Because of the nearly identical pain pattern and loca-tion, os trigonum syndrome often is confused with frac-ture of the posterior process of the talus and retrocal-caneal bursitis. A history of injury is seen with the talarfracture. Pain reproduced by resisted flexion of the greattoe is seen exclusively with os trigonum syndrome.Plain x-rays are normal, and movement of the great toeis painless with retrocalcaneal bursitis.

• Pre-Achilles bursitis is a separate condition from trueAchilles tendonitis. Bursal tenderness is located at theupper portion of the calcaneus. True Achilles tendonitisoccurs several centimeters above the calcaneus.

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CHAPTER 13: FOOT


Diagnoses

1st metatarsophalangeal (MTP) jointOsteoarthritis

Hallux valgus (bunion)Hallux rigidus

Prebunion bursaGout (podagra)SesamoiditisTurf toe

Bunionette of the 5th MTP joint

MetatarsalgiaTight extensor tendons or hammer toe deformity

(most common)Corns and callusesMorton’s neuromaRheumatoid arthritisPlantar warts

Swelling over the dorsum of the footDorsal tenosynovitisDorsal bunionStress fracture of the metatarsalsReflex sympathetic dystrophyCellulitisAnatomy: pes planus and pes cavus

Referred painLumbosacral spine radiculopathy

Tarsal tunnel syndrome

Confirmations

X-ray: foot seriesX-ray: foot seriesLocal anesthetic blockSynovial fluid analysisX-ray: sesamoid viewExamination

Examination; x-ray: foot series

Examination

ExaminationLocal anesthetic blockExamination, rheumatoid factorExamination

ExaminationX-ray: foot seriesX-ray, bone scanningBone scanningExamination, complete blood cell countExamination

Computed tomography scan, magnetic resonanceimaging, electromyography


INTRODUCTION The nontraumatic conditions affect-ing the feet can be divided into three distinct anatomic ar-eas based on the affect on ambulation, the location of pain,and the degree of swelling and inflammation: the metatar-sophalangeal (MTP) joint area of the ball of the foot, themetatarsal area of the dorsum of the foot, and the longitu-dinal ligament and plantar aponeurosis of the arch. For eacharea, unique maneuvers for examination and specific testingare needed to confirm the diagnosis.

Conditions affecting the MTP joint area are most com-mon. The pressure exerted over the ball of the foot, thegreater degree of motion, and the adverse consequences ofill-fitting shoes cause MTP joint wear (osteoarthriticchanges), gradual loss of normal alignment, and secondaryinflammatory reactions. The first MTP joint, the great toe,has the greatest susceptibility. Hallux valgus, hallux rigidus,prebunion bursitis, gout, turf toe, and sesamoiditis affectthe first MTP joint. The bunionette deformity affects thefifth MTP joint. Hammer toes and Morton’s neuroma af-fect the minor MTP joints. Combined, these conditionsdominate the differential diagnosis of foot pain.

Conditions affecting the dorsum are less common and in-clude simple edema, cellulitis, dorsotenosynovitis, reflexsympathetic dystrophy (RSD), and the swelling that ac-companies metatarsal stress fracture. All of these diag-noses are characterized by varying degrees of pain and dif-fuse swelling over the dorsum of the foot.

Conditions affecting the arch, pes cavus, pes planus, andpes planovalgus are common but rarely are the primarycause of foot pain. The variations in the configuration ofthe tarsals, metatarsals, and longitudinal ligament more of-ten play a secondary role, potentially aggravating the pri-mary cause of foot pain and dysfunction.

The primary care provider is likely to encounter many ofthe minor traumatic conditions affecting the feet. Mild tomoderate direct blows to the foot can result in nondisplacedmetatarsal fractures, minor Jones fractures of the fifthmetatarsal, fractures of the proximal phalanges, and theclassic eggshell fractures of the tuft. The majority of thesecan be readily managed with short-term restrictions in am-bulation, boot immobilization, or simple splinting withtape. Similarly, the stubbing-like injuries to the supportingligaments of the phalanges are also managed with simpletaping methods.

Finally, pain and numbness can be referred into the footfrom the lower lumbar nerve roots, from tarsal tunnel syn-drome, or from the progressive loss of sensation accompa-nying peripheral neuropathy. Lumbar radiculopathy andtarsal tunnel syndrome are the two most common extrinsicconditions that cause symptoms in the feet. Lumbar levelL4–L5 and lumbar level L5–S1 cause pain and numbnessover the dorsum and plantar surfaces, respectively.Compression and irritation of the posterior tibial nerve as itwraps around the medial malleolus causes pain and numb-ness over the plantar surface. Peripheral neuropathy fromany cause (e.g., diabetes, alcoholism) causes a diffuse loss ofsensation in a stocking–glove distribution.

SYMPTOMS Patients diagnosed with intrinsic condi-tions affecting the foot most often complain of pain, de-formity, or functional symptoms (difficulties with shoe

wear or impaired ambulation). Pain ranges from the incon-venience of tired arches to the exquisite pain of gout. TheMTP joints, the dorsal of the foot, and the arch are themost commonly affected areas. Less commonly, patientscomplain of a progressive deformity (bunions, bunionette,dorsal bunion) accompanied by functional symptoms. Thepatient’s description of the pain combined with itsanatomic location provides the most important clues to theanatomic diagnosis.

Metatarsalgia, pain in the ball of the foot, is the mostcommon pain pattern in the foot. It is a descriptive termand not a diagnosis. Any condition that directly affects theMTP joints causes either a localized or more generalizedmetatarsalgia. Pain is localized to the first MTP joint withhallux valgus, hallux rigidus, prebunion bursitis, and gout.Pain localized between two adjacent toes is most oftencaused by Morton’s neuroma. Pain localized to the fifthMTP joint is most often caused by underlying osteoarthri-tis, the bunionette deformity. In contrast, pain affectingmultiple MTP joints is caused by either the gradual devel-opment of hammer toes or the progressive effects of chronicinflammation seen with inflammatory arthritis.

The second most common group of symptoms involvesthe consequences of progressive foot deformity and how itaffects shoe wear. Patients complain of the cosmetic effectsof progressive arthritic deformity and how it leads to ill-fitting shoes. The slowly progressive and deforming forms ofosteoarthritis of the foot (hallux valgus, hallux rigidus, thebunionette deformity, and dorsal bunions) and the variouscauses of swelling over the dorsum (dorsotenosynovitis,march fracture, dorsal bunion) distort the normal contoursand alignment of the foot precluding a comfortable shoe fit.

Impairment of ambulation is a universal foot symptomfor patients with significant foot disorders. Tired feet at theend of the day, favoring of the affected side, and the in-ability to bear weight directly over the foot correlate di-rectly with the degree of acute inflammation. The greatestdegree of impairment is seen with acute gout, severe dor-sal tenosynovitis, infection, and acute inflammatoryarthritis. Pes planus and cavus, hammer toes, and the vari-ous forms of osteoarthritis cause more functional impair-ment (limiting prolonged standing and extended walking)than actual foot pain.

Foot pain accompanied by dorsal swelling is the clas-sic location of pain arising from simple edema, cellulitis,the dorsal bunion deformity, dorsotenosynovitis of theextensor tendons, and the dramatic dorsal swelling of the march fracture or underlying osteomyelitis of thetarsals or metatarsals.

Referred pain into the foot is common. Sciatica is themost common cause. The L5 root refers pain over the dor-sal aspect. The S1 root refers pain over the plantar aspect ofthe foot. Tarsal tunnel syndrome, a much less commoncause of referred pain, also causes paresthesia and hypesthe-sia over the plantar aspect of the foot.

EXAMINATION The efficient examination of the footfocuses on three distinct anatomic areas: the MTP joints(metatarsalgia), the dorsum of the foot (the metatarsals andextensor tendons), and the arch (plantar aponeurosis and longitudinal ligaments).

FOOT 251

The exam should always begin with assessment of the gen-eral function of the foot. The patient’s alignment when stand-ing, the patient’s ability to bear weight, and the ability to per-form normal heel–toe walking not only indicate overall footfunction but also define the severity of the condition.

Next, the MTP joints are inspected for proper alignment,and the MTP squeeze maneuver is performed to determinethe degree of metatarsalgia. If the MTP squeeze sign is pos-itive, joint range of motion is assessed, bony osteophytes arepalpated, extensor tendon flexibility is assessed, and the in-terdigital spaces are palpated for Morton’s neuroma.

Attention is then turned to inspection and palpation ofthe dorsum of the foot. An assessment of dorsal swellingand degree of inflammation combined with the tarsalsqueeze sign and passive flexion and isometric extension ofthe toes allows the examiner to distinguish between simpleedema or cellulitis and the reactive swelling of the marchfracture and extensor tenosynovitis.

Finally, the configuration and integrity of the arch are as-sessed by direct palpation of the arch for size and nodularthickening while the patient is standing.

If an intrinsic condition affecting the foot is not readilydiagnosed, the examiner evaluates the patient’s vascular sta-tus or seeks a referred cause of pain. Older adults with sig-nificant risk factors for peripheral vascular disease are as-sessed by capillary fill time measurement and palpation ofthe dorsalis pedis and posterior tibialis vessels. Patients withvague descriptions of pain and numbness are assessed withthe straight leg maneuver, a detailed neurologic exam, andTinel signs at the medial malleolus.

ONE-MINUTE SCREENING FOOT EXAM:MANEUVERS ASSESSING OVERALL FOOTFUNCTION

The next five maneuvers represent the minimal examinationof the patient presenting with foot symptoms. Observation ofthe patient’s ability to bear weight and walk, inspection ofthe patient’s stance, and screening maneuvers formetatarsalgia, dorsal pain and swelling, and arch abnormal-ities provide enough information to triage to x-ray, order ap-propriate labs, suggest general treatment recommendations,or proceed to more detailed examination and treatment.


Metatarsal pain Hallux valgusHallux rigidusGoutPrebunion bursaHammer toesInflammatory arthritis of the

metatarsalsMorton’s neuromaBunionette

Dorsal pain Edemaand swelling Cellulitis

Dorsal bunionReflex sympathetic dystrophyMetatarsal stress fracture

Arch of the foot Pes planusPes planovalgusPes cavusPlantar fibromatosis

Referred pain Lumbar radiculopathyTarsal tunnel syndromePeripheral neuropathy

DIFFERENTIAL DIAGNOSIS OF FOOT PAINBASED ON ANATOMIC AREA

BOX 13-1

1. Assess the general function of the foot.a. The patient’s stance.b. The ability to bear weight.c. The ability to walk heel to toe.

2. Evaluate the MTP joints for osteoarthritis and acuteswelling and inflammation.a. The MTP squeeze maneuver.b. Joint alignment.c. Toe flexibility.

3. Evaluate the dorsum of the foot: MT squeeze sign,inflammatory changes, and deformity.

4. Evaluate the arch of the foot.5. Palpate the digital nerve between two metatarsal

joints.6. Measure capillary fill times and palpate the dorsalis

pedis and posterior tibialis arteries.7. Perform Tinel sign at the medial malleolus or assess

for sciatica if referred pain is suspected.

ONE-MINUTE SCREENING EXAMINATION OF THE FOOT

BOX 13-2

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ABILITY TO BEAR WEIGHT AND WALK

SUMMARY: The ability to walk easily depends on a normal ankle joint with intact supporting tendons,flexible toe joints, intact extensor and flexor toe tendons, and a solid bony skeleton (tarsals,metatarsals, and phalangeal bones).

MANEUVER: The patient is asked to walk in theexam room. Symptoms can be enhanced by askingthe patient to toe and heel walk.

INTERPRETATION: Weight bearing is mildly im-paired with hallux valgus and rigidus, turf toe,sesamoiditis, hammer toes, dorsotenosynovitis,rheumatoid arthritis, and metatarsal stress fracture.The patient’s gait is severely affected by gout andfractures affecting the foot. Morton’s neuroma, dorsal bunion, and tarsal tunnel rarely have a significant effect on weight bearing and gait.

FIGURE 13–1. Observe the patient’s ability to bear weightand walk.

ALIGNMENT AND DEFORMITY, DORSALSWELLING

SUMMARY: Several of the common conditions af-fecting the foot can be readily diagnosed by simplyinspecting the arch of the foot, the ankle alignment,the alignment and positions of the toes, and thepresence of inflammatory changes and swelling.

MANEUVER: The patient is asked to stand on theexam platform, applying equal weight on eachfoot.

INTERPRETATION: Loss of the normal alignment of the tibia, ankle, and foot is called pronation or supination (eversion or inversion, respectively).Enlargement of the MTP joint of the great toe isseen with hallux rigidus and hallux valgus. Dorsalbunion is characterized by bony prominence overthe articulation of the first cuneiform and the firstmetatarsal. Enlargement of the fifth metatarsal iscalled the bunionette deformity. Exaggerated flex-ion of the toes is seen with hammer toes.

Swelling and inflammatory changes over the dor-sum of the foot are seen with extensor tenosynovitis,metatarsal stress fracture, RSD, and cellulitis. Acuteinflammation is seen with gout, rheumatoid arthritis,or acute prebunion bursitis.

FIGURE 13–2. Have the patient stand and inspect the toes forproper alignment and deformity and the top of the foot fordorsal swelling.


ASSESS THE PATIENT’S ARCH

SUMMARY: The arch is formed by the metatarsaland tarsal bones, the ligaments that support them,the plantar aponeurosis, and the longitudinal liga-ment. The patient must stand while the examiner assesses the configuration of the arch.

MANEUVER: The patient is asked to stand on theexam platform. The examiner palpates the arch using the middle finger.

INTERPRETATION: The examiner’s finger can be inserted up to the distal interphalangeal crease in the average arch. Flattening of the arch is called pes planus, and an exaggerated arch iscalled pes cavus. When ankle pronation is com-bined with pes planus, the condition is called pes planovalgus. Discrete nodular thickening of the arch is called plantar fibromatosis (compare this to palmar fibromatosis, Dupuytren’s contracture of the hand).

FIGURE 13–3. Assess the patient’s arch.

MTP SQUEEZE SIGN

SUMMARY: The ball of the foot is formed by thefive MTP joints. The prebunion bursa is located medial to the great toe. The digital nerves coursebetween the heads of the MTP joints (Morton’s condition). Pain over the ball of the foot is calledmetatarsalgia.

MANEUVER: All five MTP joints are compressedfrom side to side. The sign can be enhanced byholding the MTP joints of the middle, lesser toes inline with the examiner’s other hand, especially forpatients with very flexible toes.

INTERPRETATION: Any of the conditions that affectthe MTP joints will have a positive MTP squeezesign, including prebunion bursitis of the great toe,arthritis of the great toe, MTP joint inflammationfrom hammer toes, the bunionette deformity, andMorton’s neuroma. If the squeeze sign is positive,then the next step is to palpate the individual jointsand periarticular areas to define the anatomic struc-ture responsible for the symptoms.FIGURE 13–4. Perform the MTP squeeze sign.


TRIAGE TO X-RAY For a patient who has a history oftrauma or is at risk of bony injury, stress fracture, hallux val-gus, hallux rigidus, dorsal bunion, bunionette, or sesamoiditis:

• Order three views of the foot for patients with a history ofcrush injuries or direct blow to the dorsum of the foot(metatarsal fractures, the Jones fracture of the fifthmetatarsal, fracture of the proximal phalanges, theeggshell fracture of the tuft, or dislocation).

• Order three views of the foot for patients with suspectedunderlying osteoarthritis (hallux valgus, hallux rigidus, thedorsal bunion deformity, and the bunionette deformity).

• Order a posteroanterior view of the foot for athletic pa-tients or patients with known osteoporosis with swellingof the dorsum of the foot (metatarsal stress fracture).

• Order a sesamoid view for patients with pain over theplantar surface of the great toe (differentiate sesamoiditisfrom bipartite sesamoid and true fracture).

• Order three views of the foot for the athletic patient withpain on the plantar surface of the great toe (flexor tendonavulsion fracture complicating turf toe).

• Order three bilateral views of the foot for patients withdiffuse foot pain and dorsal swelling and discoloration(RSD).

TRIAGE TO THE LAB For patients with dramatic de-grees of swelling and inflammation:

• Order a complete blood cell count, uric acid, and erythro-cyte sedimentation rate for patients with acute pain, ex-quisite tenderness, inability to bear weight, and signs ofactive inflammation (gout or acute dorsotenosynovitis).

• Order a complete blood cell count, uric acid, erythrocytesedimentation rate, and blood cultures for patients withdiffuse dorsal swelling accompanied by acute inflamma-tory changes and significant fever.

CONSIDER A BONE SCAN For patients suspected ofhaving stress fracture, RSD, or osteomyelitis.

RECOMMEND EMPIRICAL TREATMENT For pa-tients with mild to moderate foot pain and stiffness, unre-stricted movement of the joints, normal alignment, andnormal gait:

• Limit walking, standing, and impact.• Wear comfortable, properly fitted shoes with padded in-

soles with or without arch supports.• Apply ice and elevate the foot four times a day.• Perform gentle daily passive stretching exercises of the

toes in extension and flexion.• Recommend an anti-inflammatory medication for 10 to

14 days at full dosage.• Use crutches with touch-down weight bearing for 5 to 7

days (optional).

FOOT 255

MT JOINT SQUEEZE SIGN

SUMMARY: The midfoot consists of the cuboid, thethree cuneiform, and five metatarsal bones. Theyare covered by a thick network of ligaments andthe extensor tendons above and the arch ligamentsbelow.

MANEUVER: The midfoot is compressed at two levels: at the level of the midshaft of the metatarsalbones and along the joint line between the tarsalbones with the metatarsals.

INTERPRETATION: This maneuver is used to screenfor pathologic involvement of the tarsal andmetatarsal bones (stress fractures, true fractures, osteoarthritis of the first cuneiform and the firstmetatarsal bones [dorsal bunion], and the rare case of osteomyelitis).

FIGURE 13–5. Perform the MT joint squeeze sign.

DETAILED EXAMINATION: SPECIFIC FOOTDIAGNOSES

HALLUX VALGUS (BUNIONS) The common term bunionis used to describe osteoarthritis of the MTP joint of the great toeaccompanied by valgus angulation. The diagnosis is suggested by

local swelling and inflammation, moderate pain with movementof the joint, and the characteristic changes of asymmetrical wear of the articular cartilage documented on x-rays. It must be distin-guished from hallux rigidus (osteoarthritis without valgus angula-tion) and gout, which is much more acute, inflamed, and painful.


PLAIN X-RAYS

SUMMARY: Symptoms arising from hallux valgusare the most common cause of metatarsalgia.Women are 10 times more likely to develop os-teoarthritis than men. The role of improper shoewear (pointed toe box) is illustrated by the fact thatmen develop hallux rigidus and women develophallux valgus.

DIAGNOSIS: Plain x-rays of the foot demonstrate osteoarthritic changes at the MTP joint and valgusangulation of the joint.

TREATMENT: Wide–toe box shoes; padded insoles;cotton, foam, or rubber spacers; bunion shields;ice; gentle flexion and extension range of motion;and local injection of 1⁄2 mL Kenalog 40 mg/mL.

REFERRAL: Surgical referral is based on the follow-ing criteria: poor shoe fit, recurrent prebunion bursitis, severe valgus angulation, and patient preference.

FIGURE 13–7. Plain x-rays to confirm and determine theseverity of hallux valgus.

SIMPLE INSPECTION OF THE FOOT

SUMMARY: Simple inspection of the foot reveals an enlarged and angulated first MTP joint. Themetatarsal head is prominent, and the great toe is angled toward the lesser toes.

MANEUVER: Simple inspection readily identifies the enlargement and angulated first MTP joint.

ASSOCIATED SIGNS: The MTP squeeze sign ispainful when the joint is acutely inflamed. Flexionand extension of the toe are limited by pain andstiffness. A bony ridge (osteophyte) can be felt atthe joint line over the dorsum. The medial aspect of the joint is discolored (irritated) or acutelyswollen and inflamed (adventitial bursitis).

INTERPRETATION: Hallux valgus and hallux rigidusare two forms of the same process: osteoarthritis ofthe first MTP joint. They differ only in the angulationof the joint. In either case, inflammation may com-plicate the osteoarthritic changes but not to the de-gree seen with gout.

FIGURE 13–6. The diagnosis of hallux valgus can be made bysimple inspection of the foot.

FOOT 257

HALLUX RIGIDUS Hallux rigidus is osteoarthritis of thefirst MTP joint (loss of range of motion of the great toe causedby wear of the articular cartilage and reactive osteophyte forma-tion). It is analogous to the findings of bunions but without valgus angulation.

JOINT ENLARGEMENT AND DECREASEDRANGE OF MOTION

SUMMARY: Arthritis of the first MTP joint is not com-mon. Most cases are a result of previous injury tothe articular cartilage from a simple strain or bonyfracture.

MANEUVER: Simple inspection of the great toe re-veals bony enlargement along the medial and supe-rior aspects of the great toe and mild degrees ofjoint inflammation. Flexion and extension of the toeare limited by pain and bony osteophyte formation.

ASSOCIATED SIGNS: The MTP squeeze sign ismildly painful. Crepitation may be present when the joint is passively flexed and extended. A bonyridge (osteophyte) can be felt over the dorsum.Ambulation is mildly impaired by the loss of full motion of the great toe.

FIGURE 13–8. A presumptive diagnosis of hallux rigidus is madeby documenting joint enlargement and decreased rangeof motion.

PLAIN X-RAYS

SUMMARY: Plain x-rays of the foot demonstrate osteoarthritic changes at the MTP joint (narrowedarticular cartilage, bony osteophytes at the margin,and bony sclerosis) with a normal angulation of the joint.

DIAGNOSIS: Moderate osteoarthritis of the first MTPjoint, hallux rigidus.

TREATMENT: Wide–toe box shoes; padded insoles;cotton, foam, or rubber spacers; ice; gentle flexionand extension range of motion; and local injectionof 1⁄2 mL Kenalog 40 mg/mL.

REFERRAL: Surgical referral is considered whensymptoms persist and at least 50% of the normalrange of motion has been lost.

FIGURE 13–9. Plain x-rays to confirm the diagnosis of halluxrigidus.

GOUT In the absence of a penetrating injury, prior surgery, orsignificant risk factors for infection (e.g., diabetes, peripheral vas-cular disease, immunodeficiency states), an empirical diagnosis ofacute gout is strongly suggested by acute swelling and inflamma-

tion and exquisite tenderness of the first MTP joint. If risk factorsare present for infection, it is necessary to aspirate the joint for syn-ovial fluid analysis: cell count, crystals, Gram stain, and culture.

PREBUNION BURSITIS The prebunion bursa, an adventitialbursa, develops as a result of constant pressure over the medial aspect of the great toe. Friction between the valgus angulatedmetatarsal head and the shoes causes dramatic swelling and

inflammation. The condition often is confused with acute gout.However, the bursal tenderness is restricted to the medial joint line,in contrast to the generalized and severe tenderness characteristic of gout.


LOCAL ANESTHETIC BLOCK AND INJECTION OF RADIO-OPAQUE DYE

SUMMARY: Because the physical signs of hallux valgus and prebunion bursitis are nearly identical,a definite diagnosis requires local anesthetic blockor the aspiration of fluid from the bursa. Enter thebursal sac medially over the point of maximumswelling (over the distal head of the metatarsal).

DIAGNOSIS: Hypaque radio-opaque dye outliningthe extent of the prebunion bursa.


DEPTH: 1⁄4 to 3⁄8 inch (1⁄8 inch above the bone).

VOLUME: 1⁄2 to 1 anesthetic, 1⁄4 to 1⁄2 mL K40, orboth.

NOTE: The bursa lies between the subcutaneous fatlayer and the synovial membrane.

REFERRAL: Surgical referral is predicated more onthe severity of the underlying hallux valgus ratherthan the involvement of the bursa.

FIGURE 13–11. Local anesthetic block and radio-opaque dye injection to confirm the diagnosis of prebunionbursitis.

SIMPLE INSPECTION

SUMMARY: Prebunion bursa is an adventitial bursathat forms as a result of repeated friction of tight fit-ting narrow–toe box shoes.

MANEUVER: Simple inspection demonstrates cysticswelling located directly over the medial aspect of thefirst MTP joint. Inflammation is limited to a quarter-sized area over the angulated metatarsal head.

ASSOCIATED SIGNS: The MTP squeeze sign ispainful. The range of motion is limited by the under-lying osteoarthritic changes but not to the extremedegree seen with acute gout. All the physical find-ings of the underlying hallux valgus are present.

INTERPRETATION: By contrast, acute gout is charac-terized by diffuse tenderness and swelling over theentire MTP joint.

FIGURE 13–10. Simple inspection readily identifies theswelling and inflammation of prebunion bursitis.

FOOT 259

GOUT

SUMMARY: Gout is an acute, crystal-induced,monarthric arthritis of the MTP joint of the greattoe. Acute swelling, redness, and heat develop asan inflammatory response to the precipitation ofmonosodium urate crystals in the synovial fluid. The synovial fluid becomes supersaturated with uricacid crystals as a result of overproduction of uricacid (hemolytic anemia, leukemia, psoriasis, tumorswith rapid cell turnover, and other causes of over-production account for 10% of cases) or under-secretion of uric acid (diuretics, renal disease, as-pirin, and niacin are the most common drugs thataccount for nearly 90% of cases).

MANEUVER: The great toe is red, hot, and swollen.Any attempts to move the joint are resisted. Com-pression of the joint from any direction is extremelypainful.

ASSOCIATED SIGNS: The MTP squeeze sign is exquisitely painful. Joint swelling is most prominentmedially but often extends between the first andsecond MTP joints. Tophaceous deposits may bepresent at other joints or along the outer ear.

INTERPRETATION: Infection in the first MTP joint israre in patients with normal immunity and no riskfactors for infection. A presumptive diagnosis ofgout can be made based on the physical findingsdescribed here and the documentation of an ele-vated blood uric acid level (90% of cases of gouthave an elevated level).

FIGURE 13–12. The empirical diagnosis of gout is suspectedwhen the first MTP joint is acutely inflamed, motion of the joint andambulation are severely limited, and the patient has no risk factorsfor infection (e.g., diabetes, vascular insufficiency, or venous ulceration).

MTP JOINT ASPIRATION

SUMMARY: A definitive diagnosis of gout is basedon the demonstration of uric acid crystals in thesynovial fluid by polarized light microscopy. Entermedially on the metatarsal or phalangeal side ofthe joint line.

NEEDLE: 5⁄8 inch, 25 gauge for anesthesia or 21gauge for aspiration.

DEPTH: 3⁄8 to 1⁄2 inch (depending on swelling).

VOLUME: 1⁄2 to 1 mL anesthetic, 1⁄4 mL K40, or both.

NOTE: Multiple attempts to enter the joint may bedamaging; with the needle flush against the perios-teum (under the synovial membrane) the needle isintra-articular; manual pressure may yield sufficientfluid for analysis.

REFERRAL: Rheumatology referral is considered for atypical presentations of gout. Surgery is not indicated.

FIGURE 13–13. MTP joint aspiration to confirm acute gout.

SESAMOIDITIS Sesamoiditis is a chronic irritation of thesesamoid bones in the flexor tendons of the first MTP joint.Repeated minor trauma causes pain and localized tenderness onthe plantar aspect of the great toe. The diagnosis is suggested by the

plantar location of the pain and tenderness that is consistently aggravated by passive stretching of the toe in extension. Bilateralsesamoid views of the forefoot are used to rule out bony fractureand congenital bipartite sesamoid.


SESAMOID VIEW OF THE FOOT

SUMMARY: The sesamoid view of the foot demon-strates ill-defined irregularities of one or both of thesesamoid bones.

DIAGNOSIS: Sesamoiditis.

TREATMENT: Non–weight-bearing activities,wide–toe box shoes, padded insoles, metatarsalbar, and ice.

REFERRAL: Surgery is not indicated.

FIGURE 13–15. Sesamoid view of the foot to confirm thediagnosis of sesamoiditis.

LOCAL PLANTAR TENDERNESS OF THE GREAT TOE

SUMMARY: The two sesamoid bones are locatedwithin the bodies of the flexor tendons of the greattoe. Repeated microtrauma causes a localized in-flammatory reaction.

MANEUVER: The first MTP joint is palpated on theplantar surface, directly over the sesamoid bones.Passive flexion and extension of the toe can facili-tate finding the exact location of the two smallbones.

ASSOCIATED SIGNS: Passive stretching of the greattoe in extension is painful at the extremes of rangeof motion. Swelling typically is too subtle to appre-ciate. The range of motion of the toe is normal.

INTERPRETATION: Major trauma to the first MTPjoint can cause sesamoid bone fracture. X-raysdemonstrate an irregular fracture line. This is instark contrast to the well-demarcated line seen withbipartite sesamoid bone, which is often bilateral.

FIGURE 13–14. Local plantar tenderness of the greattoe in a patient with a history of repeated minor trauma.

TURF TOE Young athletes playing on artificial turf are at riskfor hyperextension injury of the first MTP joint, causing stretchingof and strain on the capsule of the joint and the plantar plate. Thepatient describes a deep aching in the bone associated with localtenderness over the entire joint. This is in contrast to the tenderness

localized to the plantar aspect of the joint suggesting sesamoiditisor fracture. Range of motion should be preserved, and x-raysshould be normal unless avulsion fracture complicates the injury.Treatment includes buddy taping of the joint, stiff shoes, and a stifforthotic for 2 to 3 weeks.

FOOT 261

TURF TOE

SUMMARY: Turf toe is seen almost exclusively in ath-letes performing on artificial turf.

MANEUVER: The patient’s pain is reproduced bypassive stretching of the first MTP joint in full exten-sion. This places strain on the joint capsule, theflexor tendons, and the plantar plate.

ASSOCIATED SIGNS: The plantar aspect of the firstMTP joint may be diffusely tender to direct palpa-tion. The range of motion in flexion and extensionis minimally reduced, restricted more by discomfortthan by an absolute loss of movement.

INTERPRETATION: The symptoms of turf toe andsesamoiditis overlap. Turf toe occurs only in athletessubject to the trauma of artificial turf. The plantartenderness of sesamoiditis is much more focal. X-rays are necessary to exclude tendon avulsion or true bony fracture.FIGURE 13–16. Turf toe is a diagnosis of exclusion. Before

the diagnosis can be made in an athlete, fracture, hallux rigidus,sesamoiditis, and hallux valgus must be excluded by exam and radiographic studies.

HISTORY, CLINICAL FINDINGS, AND FOOT X-RAY

SUMMARY: Plain x-rays of the foot and sesamoidviews are used to exclude tendon avulsion, truebony fracture, and sesamoiditis.

DIAGNOSIS: Normal posteroanterior x-ray of thefoot in a patient with turf toe.

Treatment: Wide–toe box shoes; padded insoles;cotton, foam, or rubber spacers; ice; gentle flexionand extension range of motion; and intra-articularinjection of 1⁄2 mL Kenalog 40 mg/mL.

REFERRAL: Surgical referral is recommended for ten-don avulsion accompanying turf toe.

FIGURE 13–17. An appropriate history coupled with consistentclinical findings and a normal foot x-ray are necessary for adiagnosis of turf toe.

BUNIONETTE The common term bunionette is used to describeosteoarthritis of the fifth MTP joint complicated by varus angula-tion. The diagnosis is suggested by local swelling and inflammation,moderate pain with movement of the joint, and the characteristicchanges of asymmetrical wear of the articular cartilage.


POSTEROANTERIOR X-RAY OF THE FOOT

SUMMARY: Plain x-rays of the foot demonstrate osteoarthritic changes at the fifth MTP joint with a varus angulation of the joint.

DIAGNOSIS: Bunionette deformity of the fifth MTPjoint.


REFERRAL: Surgical referral is based on the follow-ing criteria: poor shoe fit, recurrent skin irritation,severe varus angulation, and patient intolerance or preference.

FIGURE 13–19. Posteroanterior x-ray of the foot is usedto confirm the diagnosis of bunionette.


SUMMARY: Simple inspection of the foot reveals an enlarged and angulated fifth MTP joint. Themetatarsal head is prominent, and the little toe is angled toward the other toes.

MANEUVER: Simple inspection readily identifies the enlargement and angulated fifth MTP joint.

ASSOCIATED SIGNS: The MTP squeeze sign ispainful when the joint is acutely inflamed. Flexionand extension of the toe are limited by pain andstiffness. A bony ridge (osteophyte) can be felt atthe joint line over the dorsum. The lateral aspect of the joint can be discolored (irritated) or acutelyswollen and inflamed (adventitial bursitis).

INTERPRETATION: As osteoarthritis progresses, theangle of the toe gradually increases.

FIGURE 13–18. The diagnosis of bunionette can be made bysimple inspection of the foot.

METATARSALGIA Metatarsalgia (pain over the ball of thefoot) is the pain arising from the metatarsal joints or the sur-rounding soft tissues. Because metatarsalgia is a general term,

a thorough search for a specific underlying diagnosis, such as hal-lux valgus, hallux rigidus, prebunion bursitis, hammer toes, gout,rheumatoid arthritis, or Morton’s neuroma, must be undertaken.

FOOT 263

MTP SQUEEZE SIGN

SUMMARY: Metatarsalgia is a descriptive term only,not a specific diagnosis.

MANEUVER: The MTP squeeze sign is used to iden-tify the ball of the foot as the source of the patient’spain.

ADDITIONAL SIGNS: Swelling and tenderness lim-ited to the medial side of the great toe are diagnos-tic of prebunion bursitis. Loss of range of motion,bony enlargement, and variable degrees of inflam-mation are seen with hallux valgus and halluxrigidus. Intense pain and inflammatory change inthe great toe are the classic presentation of gout.Lack of toe flexibility and generalized metatarsalpain are seen with hammer toes and rheumatoidarthritis. Pain and numbness limited to the third andfourth or second and third toes are consistent withMorton’s neuroma. Pain, deformity, and decreasedrange of motion in the fifth MTP joint are diagnosticof the bunionette deformity.

INTERPRETATION: The metatarsal squeeze sign is an excellent screening test to identify the ball of the foot as the source of the patient’s problem.However, additional testing is necessary to definethe exact anatomic cause.

FIGURE 13–20. MTP squeeze sign is used to screen the MTPjoints or associated soft tissues as the source of the patient’s pain.

METATARSALGIA INVOLVING A SINGLE MTP JOINT

SUMMARY: Occasionally one of the lesser toes sus-tains a remote injury (severe strain or fracture) thatdamages the articular cartilage and increases sus-ceptibility to irritation and inflammation.

MANEUVER: Selective MTP joint involvement is con-firmed by direct palpation of the affected joint.Compression of the joint from above and below istender or thickened. Passive flexion and extensionare limited. Plain x-rays of the foot may demon-strate osteopenia, osteoarthritic changes, or normalfindings.


REFERRAL: Surgery is not indicated.

FIGURE 13–21. Metatarsalgia involving a single MTPjoint is seen with trauma, posttraumatic arthritis, or the selectedinflammatory arthritis as a part of spondyloarthropathy.

HAMMER TOES The hammer toe deformity results from theprogressive loss of flexibility of the extensor tendons of the toes andis a specific cause of metatarsalgia. As the extensor tendons gradu-ally tighten, subluxation of the tendons over the top of the proxi-

mal phalanges results in the characteristic deformity: abnormalflexion of the proximal interphalangeal joint and extension of thedistal interphalangeal joint. Metatarsal pain, corns, and callusesoften develop years before the deformity.


CLINICAL DIAGNOSIS OF HAMMER TOES

SUMMARY: Patients with the classic hammer toe deformity do not need further testing. Plain x-raysdemonstrate the cocked-up position of the toes inmoderate cases.

DIAGNOSIS: Severe hammer toe deformity.

TREATMENT: Wide–toe box shoes; padded insoles;cotton, foam, or rubber spacers; hammer toe crestsplaced under the toes; paring of the associatedcorns and calluses; passive stretching of the extensor tendons; local injection of 1⁄2 mL Kenalog40 mg/mL.

REFERRAL: Surgical referral can be considered forthe rigid, fixed hammer toe deformity that severelyinterferes with overall foot function and shoe wear.

FIGURE 13–23. A clinical diagnosis of hammer toes issufficient in most patients with classic findings. Further testing usu-ally is not necessary.

LACK OF FLEXIBILITY OF THE EXTENSORTENDONS

SUMMARY: The gradual tightening of the extensortendons of the toes has predictable consequences.The gradual tendon contracture causes the toes tocock up and the metatarsal joints to project in adownward direction. Corns and calluses form as a result of the pressure atop the toes and below the metatarsal heads, respectively. Ultimately, thetendons slip off the sides of the toes, leading to the fixed contracture and hammer toe deformity.

MANEUVER: Simple inspection with the foot in theplantar flexed position demonstrates the prominentextensor tendons, the cocked-up toes, and the asso-ciated hypertrophic skin changes (corns and cal-luses). The signs can be enhanced by passive flex-ion of the toes.

ADDITIONAL SIGNS: The MTP squeeze sign usuallyis positive. Individual joints may be selectively moresensitive to compression. The range of motion ofthe MTP joints is preserved (the joints have normalflexibility when the ankle is fully dorsiflexed, relax-ing the tight tendons).

INTERPRETATION: In the earliest stages of hammertoes, the physical findings overlap with the earlysigns of rheumatoid arthritis. X-rays of the foot mayshow juxta-articular osteoporosis with rheumatoidarthritis (the earliest radiographic finding) However,it may take serial examination, x-rays, and serologi-cal testing to distinguish the two conditions.

FIGURE 13–22. Lack of flexibility of the extensor ten-dons of the toes characterizes hammer toes.

MORTON’S NEUROMA A presumptive diagnosis ofMorton’s neuroma is suggested by a positive MTP squeeze sign,local tenderness, and hypesthesia between two adjacent toes. The

diagnosis can be confirmed by local anesthetic block placed at thelevel of the digital nerve, response to corticosteroid injection, or re-sponse to surgical intervention.

FOOT 265

MTP SQUEEZE SIGN, LOCAL TENDERNESS,AND HYPESTHESIA

SUMMARY: Morton’s neuroma, a digital neuromalocated between the metatarsal heads of two adja-cent toes, is caused by the constant compression of the nerve from the pressures of walking and thepressures of the adjacent metatarsal heads.

MANEUVER: After the examiner screens the MTPjoints with the MTP squeeze sign, the individualspaces between the metatarsal heads are com-pressed from above and below. A positive re-sponse is indicated by localized tenderness or byreproducing the patient’s hypesthesia along the inside of two toes.

ASSOCIATED SIGNS: The MTP joints are not tenderto compression. Long-lasting cases may show hy-pesthesia to light touch and pain sensation alongthe inner aspect of the adjacent toes. Rarely a pal-pable mass can be felt between the toes. Move-ment of the toes in flexion and extension is notpainful.

INTERPRETATION: The signs listed here are uniquefor Morton’s neuroma.

FIGURE 13–24. The combination of a positive MTP squeezesign and local tenderness and hypesthesia of two adjacenttoes strongly suggests the diagnosis of Morton’s neuroma.


SUMMARY: Local anesthetic block of the digitalnerve is placed below the transverse metatarsal ligament. The neurovascular bundle is located justunder the ligament. The injection enters fromabove, 1⁄2 inch distal to the MTP joint.


DEPTH: 5⁄8 to 3⁄4 inch (below the transversemetatarsal ligament).

VOLUME: 1⁄2 mL anesthetic, 1⁄4 mL K40, or both.

NOTE: This injection is identical to a digital block.

REFERRAL: Surgical referral is indicated when twoor three local injections within 1 year fail to controlsymptoms.

FIGURE 13–25. Local anesthetic block to confirm the diag-nosis of Morton’s neuroma.

METATARSAL STRESS FRACTURE (MARCH FRACTURE)Microfracturing of the shafts of the metatarsal bones leads to agradual thickening of the periosteum and the characteristic enlarge-

ment of the cortex. Although this stress fracture occurs most com-monly in long-distance runners, military recruits, and balletdancers, patients with severe osteoporosis are also at risk.


SERIAL PLAIN X-RAYS OR BONE SCANNING

SUMMARY: A definitive diagnosis can be madewith plain x-rays or bone scanning. Patients withsymptoms for several weeks demonstrate periostealthickening along the shaft of the bone on plain x-rays. A true fracture line is not seen unless the patient suffers additional blunt trauma. By contrast, nuclear bone scanning demonstrates periosteal uptake within the first few weeks of symptoms.

DIAGNOSIS: Stress fracture affecting the secondmetatarsal.

TREATMENT: Wide–toe box shoes, padded insoles,restricted weight bearing (walking and standing), a shortened stride, and a short leg walking cast.

REFERRAL: Surgical consultation is indicated if thebone fails to heal.

FIGURE 13–27. Metatarsal stress fracture is confirmed by serialplain x-rays or bone scanning.

FOCAL METATARSAL PAIN AND DORSALSWELLING

SUMMARY: In the absence of major trauma, focaltenderness over a single metatarsal bone in a run-ner, military recruit, ballet dancer, or patient withknown osteoporosis indicates stress fracture.

MANEUVER: Each metatarsal shaft is palpated forlocal tenderness and bony prominence.

ASSOCIATED SIGNS: The MT squeeze sign is mod-erately painful. The entire dorsum of the foot maybe swollen, as long as peripheral edema, dor-sotenosynovitis, RSD, and cellulitis are excluded.Inflammatory signs typically are not present.

INTERPRETATION: The swelling of metatarsal stressfracture overlaps with the swelling of edema, celluli-tis, and dorsotenosynovitis. Only stress fractureshave a positive MT squeeze sign. Dorsoteno-synovitis is aggravated by movement of the toes.Edema, cellulitis, and RSD are not aggravated bythe MT squeeze sign or movement of the toes.

FIGURE 13–26. Focal metatarsal pain and dorsalswelling consistent with metatarsal stress fracture.

DORSAL TENOSYNOVITIS Inflammation of the extensortendons of the foot is called dorsal tenosynovitis. It is characterizedby dorsal pain, swelling, and acute inflammation. In addition,the pain of active tenosynovitis is uniquely aggravated by resisted

extension and passive flexion of the toes. The latter sign distin-guishes it from the conditions that cause dorsal swelling (simpleedema, cellulitis, march fracture, osteomyelitis, and RSD).

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DORSAL INFLAMMATORY SWELLING

SUMMARY: Dorsotenosynovitis can result from thefriction of tight-fitting shoes, the migratory tenosyn-ovitis of gonorrhea, the tenosynovitis of establishedrheumatoid arthritis, and the acute inflammation ofgout or pseudogout.

MANEUVER: Simple inspection of the dorsum of thefoot extending from the base of the toes to the an-kle is swollen, warm to the touch, and discolored.The entire area is tender to the touch.

ASSOCIATED SIGNS: Dorsal foot pain is repro-duced by resisted extension of the toes and passiveflexion of the toes. The MT squeeze sign is mini-mally painful (compare with metatarsal fracture).

INTERPRETATION: The swelling of dorsotenosynovitisoverlaps with the swelling of edema, cellulitis, andmetatarsal stress fracture. Only dorsotenosynovitis is aggravated by movement of the toes. Stress frac-tures have a positive MT squeeze sign. Edema andcellulitis are not aggravated by the MT squeezesign or movement of the toes.

FIGURE 13–28. Dorsal inflammatory swelling of dorsaltenosynovitis.

CLINICAL DIAGNOSIS OFDORSOTENOSYNOVITIS

DIAGNOSIS: No specialized testing is available toconfirm the diagnosis of dorsotenosynovitis. Dorsalswelling, pain reproduced by resisting toe exten-sion, and pain aggravated by passive toe flexionremain the hallmarks of this local musculoskeletalprocess.

TREATMENT: Loose-fitting shoes, double socks for ex-tra padding, ice, a full-dose NSAID for 10–14days, and treatment for gout or rheumatoid arthritis.

REFERRAL: Surgery is not indicated

FIGURE 13–29. Clinical diagnosis of dorsotenosynovitisis based solely on the examination.

DORSAL BUNIONOsteoarthritic wear between the first cuneiform and the firstmetatarsal bone is manifested by a narrowing of the joint and re-active osteophyte formation. The firm to hard prominence palpable

over the dorsum of the foot is called a dorsal bunion. The diagno-sis is confirmed by a lateral radiograph demonstrating the charac-teristic arthritic changes.


PLAIN X-RAY OF THE FOOT

SUMMARY: Plain x-rays of the foot demonstrate os-teoarthritic changes at the articulation of the firstmetatarsal and the first cuneiform. Osteophyte formation on the dorsal side of the joint causes thebunion.

DIAGNOSIS: Osteoarthritis of the first cuneiformand the first metatarsal bone with reactive osteo-phyte formation and near obliteration of the articu-lar cartilage.

TREATMENT: Loose-fitting shoes, double socks for extra padding, adhesive donut padding placedover the bunion, and ice.

REFERRAL: Surgical referral is warranted whenshoes fit poorly, skin irritation develops recurrently,or the patient requests it.

FIGURE 13–31. Plain x-ray of the foot confirms the diagno-sis of dorsal bunion.


SUMMARY: Arthritis between the cuneiform and themetatarsal bones is uncommon. Previous fracture,pes planus, and pes cavus are risk factors.

MANEUVER: Simple inspection readily identifies the localized arthritic changes on the medial sideof the midfoot. The articulation between the firstcuneiform and the first metatarsal bone is enlargedand bony hard to palpation. The surrounding skin,typically the size of a quarter, may show mild inflammation.

ASSOCIATED SIGNS: The MT squeeze sign ismildly painful. Passive and resisted movement ofthe extensor tendons of the toes does not causepain.

INTERPRETATION: Bony enlargement over the articu-lation of the first cuneiform and first metatarsal is diagnostic of dorsal bunion.

FIGURE 13–30. Simple inspection of the foot in the diag-nosis of dorsal bunion.

PES PLANUS, PES CAVUS Inspection of the medial aspect ofthe foot while the patient is standing and palpation of the longitu-dinal ligament and plantar aponeurosis for nodular thickeningare the best means of evaluating these variations of the configura-tion of the arch.

FOOT 269

SIMPLE INSPECTION OF THE ARCHCONFIGURATION

SUMMARY: The arch is formed by the metatarsaland tarsal bones, the ligaments that support them,the plantar aponeurosis, and the longitudinal liga-ment. The patient must stand while the examiner assesses the arch configuration.

MANEUVER: The patient is asked to stand on theexam platform. The examiner palpates the arch us-ing the middle finger. The examiner’s finger can beinserted up to the distal interphalangeal crease inthe average arch.

ADDITIONAL SIGNS: The alignment of the ankle ismost affected by pes planus. When ankle pronationis combined with pes planus, the condition is calledpes planovalgus. Discrete nodular thickening of thearch is called plantar fibromatosis (compare withDupuytren’s contracture of the hand or palmar fibro-matosis). Plantar fasciitis and Achilles tendonitis canaccompany the more severe arch abnormalities.

INTERPRETATION: Pes planus, pes cavus, and pesplanovalgus are unique configurations of the footand are readily diagnosed by inspection of the patient’s stance and palpation of the arch.

FIGURE 13–32. Simple inspection of the arch configura-tion with the patient standing.

PALPATION OF THE ARCH

SUMMARY: Flattening of the arch is called pesplanus, and an above-average arch is called pes cavus.

TREATMENT: Comfortable shoes, fatigue mat tostand on, padded insoles with arch supports formild pes planus, and custom-made insoles for mod-erate to severe pes planus and pes cavus.

REFERRAL: Patients are referred to a podiatrist mostoften for molding of the feet to make custom archsupports.

FIGURE 13–33. A definitive diagnosis of pes planus or pescavus requires palpation of the arch.

REFLEX SYMPATHETIC DYSTROPHY Any condition thatreduces the normal movement of the lower extremity (e.g., injury,immobilization, surgery) alters the normal balance between the afferent and efferent system of nerves that innervate the lower ex-tremity. Reduced movement of the leg, ankle, and foot decreases the

normal afferent activity (inhibitory to the sympathetic nervous sys-tem at the level of the spinal cord), which in turn increases the ef-ferent activity and sympathetic tone. High sympathetic tone causesdiffuse pain, edema, discoloration, vasodilation, and increased os-teoclastic activity.


REFLEX SYMPATHETIC DYSTROPHY

SUMMARY: RSD represents a combination of symp-toms that result from an impairment of overall move-ment of the lower extremities. The lack of movementcauses an imbalance between the afferent and ef-ferent nervous systems, ultimately leading to an in-crease in sympathetic tone.

MANEUVER: Simple inspection and palpation of thedorsum of the foot demonstrate diffuse edema, dis-coloration, skin sensitivity, and an unusual andwidespread tenderness encompassing soft tissue,joints, and bone.

ASSOCIATED SIGNS: The foot and ankle joints retain their normal range of motion. As the condi-tion progresses, the foot takes on a reddish-purple, shiny hue. Capillary fill is delayed on the affected side. The foot may have a subtle difference in temperature.

INTERPRETATION: RSD should be suspected in pa-tients with impaired ambulation, diffuse ankle andfoot pain, diffuse swelling of the dorsum, and diffusetenderness throughout the ankle and foot. The diffusepain pattern and widespread tenderness distinguishthis neurogenic condition from the local muscu-loskeletal conditions including metatarsal stress frac-ture, edema, cellulitis, and dorsotenosynovitis.

FIGURE 13–34. A history of impaired lower extremity move-ment, diffuse pain involving the foot and ankle, and an examdemonstrating diffuse edema, discoloration, and sensitivity sug-gests reflex sympathetic dystrophy.

SERIAL X-RAYS OR BONE SCANNING

SUMMARY: Plain x-rays of the foot showing unilat-eral diffuse osteopenia (Sudeck’s atrophy of bone)is highly suggestive of RSD. However, the definitivediagnosis requires bone scanning. A diffuse unilat-eral uptake of the radioisotope over the entire footon the perfusion phase of the scan is diagnostic of RSD.

DIAGNOSIS: Reflex sympathetic dystrophy.

TREATMENT: Physical therapy range of motion exercises and stimulation of the extremity, ice andelevation for swelling, a tapering dosage of pred-nisone from 30 to 40 mg/day, and progressive ambulation.

REFERRAL: Patients with persistent symptoms overmonths despite physical therapy and oral pred-nisone can be considered for diagnostic sympa-thetic nerve block. If symptoms respond to nerveblock, referral to the neurosurgeon for sympathec-tomy can be considered.

FIGURE 13–35. Serial x-rays or bone scanning are usedto confirm the diagnosis of RSD.



Valgus deformity of the MTP joint #1: Bunions Osteoarthritic changes and valgus angulation of the MTP joint on anteroposterior x-ray of the foot

� MTP squeeze (1st MTP pain)

Loss of MTP range of motion

Palpable dorsal spurring

� MTP squeeze (MTP pain) Hallux rigidus Osteoarthritic changes with normal alignment of the MTP joint on anteroposterior x-rays

Loss of MTP range of motion

Palpable dorsal spurring

Medial MTP joint swelling and acute inflammation Prebunion bursitis Local anesthetic block placed intrabursa

� MTP squeeze sign (medial pain only)

Underlying bunion

Severe MTP joint swelling and acute inflammation Acute gout (podagra) Synovial fluid aspiration showing intracellular and birefringent uric acid crystals or prompt response to treatment with concurrent elevated uric acid

� MTP squeeze (exquisite MTP joint pain)

Severe pain with passive MTP joint movement

Focal tenderness over the plantar surface Sesamoiditis Sesamoid view of the footof the MTP joint

Pain aggravated by passive dorsiflexion of the flexor tendons

Tight extensor tendons with the ankle Metatarsalgia, hammer toes Diagnosis by clinical examinationin full plantarflexion

� MTP squeeze (diffuse MTP pain)

Normal MTP joint range of motion

Secondary corns and calluses

Hammer toe deformity (late)

Focal tenderness in between two MTP joints Morton’s neuroma Diagnosis by local anesthetic block placed between two MTP joints and below the transverse metatarsal ligament

� MTP squeeze sign (pain between two MTP joints)

Hypesthesia along the inner aspect of the adjacent two toes

Varus bony deformity of the fifth MTP joint Bunionette Osteoarthritic changes and varus angulation of the MTP joint on anteroposterior x-rays of the foot

� MTP squeeze sign (5th MTP joint pain)

Focal tenderness and swelling directly over the Metatarsal stress fracture Periosteal thickening of the 3rd or 4th metatarsal bone or midportion of the affected metatarsal increased uptake on bone scan

� Metatarsal (midfoot) squeeze sign

Diffuse dorsal swelling of the foot

Pain with passive plantarflexion of the toes Dorsal tenosynovitis Diagnosis by clinical examination

Diffuse dorsal swelling of the foot

Pain with resisted toe extension

Bony deformity over the dorsum of the foot Dorsal bunion Oblique view of the foot showing arthritic spurring between the first metatarsal and the first cuneiform

Focal tenderness with or without swelling

Mild erythema

Flat or exaggerated arch while standing Pes planus, pes cavus Diagnosis by clinical examination

Associated ankle pronation

FOOT 271

COMMON FOOT FRACTURESCHARCOT ORNEUROPATHIC FRACTURES


FRACTURES OF THE MIDTARSALS

SUMMARY: Midtarsal fractures are rare because of the rigidity of the midfoot. Most occur as a resultof a direct blow to the dorsum of the foot. Point ten-derness over the affected bone is accompanied bypain aggravated by side-to-side compression of thefoot at the level of the tarsals or tarsal–metatarsaljunction (the T or MT squeeze signs).

DIAGNOSIS: Figure 13–36 depicts the Lisfranc fracture–dislocation at the first cuneiform and firstmetatarsal joint.

REFERRAL: Surgical referral is indicated for all butthe simple nondisplaced, well-aligned fractures.

FIGURE 13–36. Fractures of the midtarsals.

CHARCOT OR NEUROPATHIC FRACTURESPatients with impaired sensation caused by peripheral neu-ropathy are at risk for fracture and impaired fracture healing.Often such patients present with localized swelling and ery-

FOOT 273

thema that is disproportionate to the average amount of re-active soft tissue change for that particular fracture. The mid-foot often is the site of these fractures. Nonunion and malu-nion of the fracture are common with delayed diagnosis.

FRACTURES OF METATARSALS 1–4

SUMMARY: A metatarsal fracture is most oftencaused by a direct blow to the top of the foot. Suchfractures are classified according to the mechanismof injury (stress fractures), the location (base, neck,or shaft), the direction of the fracture line (trans-verse or spiral), and the displacement.

DIAGNOSIS: Transverse fractures of metacarpals 2 through 4.

IMMOBILIZATION: Nondisplaced fractures of theneck or shaft of metatarsals 2 through 4 can betreated with ice, elevation, analgesia, and a shortleg walking cast. Nondisplaced fractures of the firstmetatarsal are treated similarly but with the addition of a 2- to 3-week period of non–weight-bearing casting followed by a short leg walkingcast to complete the 5-week immobilization.

SURGICAL REFERRAL: Displaced metatarsal fractureswarrant referral to an orthopedic surgeon for reduc-tion and internal fixation.

FIGURE 13–37. Fractures of metatarsals 1–4.

FRACTURES OF THE FIFTH METATARSAL BONE

SUMMARY: Fractures of the fifth metatarsal areunique. The Jones fracture involves tuberosity of thebase of the metatarsal. It should not be confusedwith a transverse fracture of the base, which has avery different prognosis. The Jones fracture is com-monly located within 3⁄4 inch of the most proximalportion of the metatarsal.

DIAGNOSIS: Jones fracture of the fifth metatarsal.

IMMOBILIZATION: It is usually treated with a bulkyJones dressing for the first 24 to 36 hours andavoidance of weight bearing, followed by a shortleg walking cast for 3 to 4 weeks. A transversefracture of the shaft of the fifth metatarsal is treatedwith a short leg walking cast.

SURGICAL REFERRAL: There is a high incidence ofdelayed union and of nonunion of this fracture de-spite proper immobilization. These patients needthe expertise of the fracture specialist.

FIGURE 13–38. Fractures of the fifth metatarsal bone.


FRACTURES OF THE GREAT TOE

SUMMARY: Fracture of the proximal phalanx of the great toe occurs as a result of direct trauma(dropped objects) or a stubbing injury. Most fractures show minimal displacement.

DIAGNOSIS: Minimally displaced fracture of theproximal phalanx of the great toe.

IMMOBILIZATION: Treatment includes buddy tap-ing, stiff shoes, or a short leg walking cast with a toe plate for 2 weeks. Displaced intra-articularfractures can be reduced with finger traps and then treated in the same fashion as nondisplacedfractures.

FIGURE 13–39. Fractures of the great toe.

FRACTURE OF THE SESAMOID BONE

SUMMARY: Fractures of the sesamoid bone (medialaspect fractures are much more common than lat-eral aspect fractures) must be distinguished from thecongenital bipartite sesamoid. True fractures haverough edges, are transverse in direction, and even-tually show callus formation. Bipartite sesamoidfractures occur bilaterally and have smooth, sharplybordered edges. Most fractures occur as a result ofdirect trauma, avulsion forces, or repetitive stress.

DIAGNOSIS: Sesamoid fracture.

IMMOBILIZATION: Treatment with a short leg walk-ing cast for 3 to 4 weeks is followed by a stiff shoeand a metatarsal bar or pad.

FIGURE 13–40. Fracture of the sesamoid bone.

FOOT 275

FRACTURES OF THE TOES

SUMMARY: Fractures of the lesser toes are easily re-duced with manual pressure or finger traps. Buddytaping to the adjacent larger toe with cotton placedin the toe web is the treatment of choice.

FIGURE 13–41. Fractures of the toes.


• Osteoarthritis of the great toe with normal alignment iscalled hallux rigidus and hallux valgus if the toe is an-gulated. The conditions are otherwise identical in symp-toms, signs, and radiographic changes.

• Acute prebunion bursitis often is misdiagnosed as acutepodagra. Acute gout involvement of the great toe ischaracterized by diffuse swelling and inflammation andpain aggravated by motion of the joint in any direction.Acute prebunion bursitis is tender, swollen, and in-flamed only along the medial aspect of the joint overthe metatarsal head.

• Metatarsalgia is a term describing pain arising from anyof the structures of the ball of the foot (bunions, gout,prebunion bursitis, hammer toes, bunionette, rheuma-toid arthritis, and Morton’s neuroma).

CLINICAL PEARLS

• The earliest manifestation of hammer toes is a tighten-ing and loss of flexibility of the extensor tendons of thetoes (the most common cause of metatarsalgia).

• Cellulitis and acute inflammatory dorsal tenosynovitispresent with similar dorsal swelling and acute inflam-matory change. Cellulitis involves the dermis and there-fore should not be aggravated by passive flexion of thetoes and resisted extension of the toes.

• The presence of corns and calluses over the metatarsalheads should alert the clinician to early hammer toes(loss of normal flexibility of the extensor tendons,metatarsalgia).

ACCESSORY BONES OF THE FEET

SUMMARY: The accessory bones occur in a variety oflocations. Radiographically, they are sharply defined,well-circumscribed, oval or round ossifications adja-cent to the tarsal or metatarsal bones. They are signif-icant only because they are often misinterpreted asfractures. Their specific locations and distinctiveanatomic features should differentiate them from avulsions and small fragment fractures of the bonesof the feet.

ACCESSORY BONES OF THE FEET: The accessorybones of the feet are significant because they canmimic fractures.1. Os trigonum2. Os sustentaculum3. Talus accessories4. Os subcalcis5. Os tibiotibiale6. Calcaneus secundarium7. Os supranaviculare8. Os supratalare9. Os tibiale externum

10. Os intercuneiforme11. Os peroneum12. Os vesalianum13. Os intermetatarseum

FIGURE 13–42. Accessory bones of the feet.

277

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295

INDEX

AAbdomen

low back pain referred from, 169palpation of, 169shoulder pain referred from, 44

Achilles tendon rupture, 234, 244Achilles tendonitis, 223, 234, 244, 249Acromioclavicular joint

differential diagnosis, 19local anesthetic block of, 38osteoarthritis of, 20, 25, 37–38, 45, 49palpation of, 25, 37separation of, 20, 37–38, 45

third-degree, 39, 45Acute boutonnière deformity, 119, 135Adhesive capsulitis, 20Adson maneuver, 13, 14Ambulation impairment, 251Anesthetic blocks

intra-articular, for ankle arthritis, 232local. See Local anesthetic blocks

Angiography, for aortoiliac vascular occlusivedisease, 189

Anklealignment of, 225anterior talofibular ligament of, 249arthritis of, 232–233, 244description of, 223differential diagnosis, 222eversion of, 226, 233

isometric resistance of, 242examination of, 223–224extension of, 226flexion of, 226fractures of, 245–249instability of, 230, 244inversion of, 226, 233

isometric resistance of, 241lateral ligament tenderness and swelling of,

229one-minute screening examination of,

224–228osteoarthritis of, 232–233, 244passive stretching of, 226, 229range of motion testing, 226referred pain, 222rheumatoid arthritis of, 232–233stress views of, 231traumatic injuries of, 222weight bearing, 225

Ankle painanterior, 223, 224lateral, 223, 224medial, 223, 224posterior, 223, 224symptoms of, 223, 224

Ankle spraindescription of, 223, 249diagnosis of, 229–231, 244instability associated with, 230, 244

Anserine bursa, 201, 209Anserine bursitis, 209, 217, 221Antecubital fossa, 77Anterior ballottement, 232Anterior cruciate ligament injury, 212, 217Anterior drawer sign, 212, 230Anterior talofibular ligament, 249Anterolateral thigh sensation testing, 185Anteroposterior x-ray

pelvic, for hip osteoarthritis evaluations, 182spinal, for scoliosis, 60, 65, 163

Aortoiliac vascular occlusive disease, 189, 192Apley scratch sign, 22, 31Apprehension test, 41Arch of foot, 251, 254Arthritis

ankle, 232–233distal interphalangeal joint, 133hip joint, 183–184interphalangeal joint, 109metacarpophalangeal joint, 102, 109, 114, 130osteoarthritis. See Arthritisradiocarpal joint, 90–91, 96rheumatoid. See Rheumatoid arthritissubtalar, 223, 233, 244traumatic, of metacarpophalangeal joint,

130, 133ulnarhumeral joint, 75–76

Arthrographyof glenohumeral joint, 32of rotator cuff, 34

Arthroscopyanterior cruciate ligament injury, 212meniscal tears, 214

Aspirationof ankle, 232for Baker’s cyst diagnosis, 213of dorsal ganglion, 92of elbow, 76for glenohumeral joint osteoarthritis, 40of hip joint, 184of knee joint, 206metatarsophalangeal joint, for gout

diagnosis, 259for olecranon bursitis diagnosis, 73of prepatellar bursa, 207for radiocarpal joint arthritis, 91

Avascular necrosisof hip joint, 186, 192of navicular bone, 99

BBaker’s cyst, 197, 213, 217, 221Biceps insertionitis, 77, 79Bicipital groove, 35Bicipital tendon rupture, 36Bicipital tendonitis, 35–36, 45Bilateral sunrise x-rays, 203Blocks, anesthetic

intra-articular, for ankle arthritis, 232local. See Local anesthetic blocks

Bone scanfor ankle conditions, 228for avascular necrosis of hip joint, 186for calcaneal stress fracture, 240for chest conditions, 142for compression fractures of lumbosacral

spine, 165for elbow conditions, 70for foot conditions, 255for hand conditions, 122for hip conditions, 178for knee conditions, 202for lumbosacral spine conditions, 155for metastatic disease of femur, 188for neck conditions, 6for occult hip fracture, 187for reflex sympathetic dystrophy, 270for shoulder conditions, 27for thumb conditions, 107for upper back conditions, 56for wrist conditions, 88

Boutonnière deformity, 119, 135Breathing pattern assessments

for chest evaluations, 139for upper back evaluation, 53

Buniondiagnosis of, 256, 271dorsal, 268, 271

Bunionette, 262, 271Bursa

anserine, 201, 209gluteus medius, 177olecranon, 70, 73pre-Achilles, 235, 244prebunion, 258prepatellar, 201, 207subscapular

description of, 20palpation of, 26, 54, 59

Bursitisanserine, 209, 217, 221gluteus medius

description of, 173, 194diagnosis of, 180–181, 192

olecranonacute, 73chronic, 73description of, 67needle aspiration for, 73summary of, 79

pre-Achilles, 235, 244, 249prebunion, 258, 271, 276prepatellar, 207, 217retrocalcaneal, 236, 244subacromial, 20subscapular, 42, 45, 59, 65trochanteric

description of, 173, 192diagnosis of, 178–179referred pain from, 194

CCalcaneal compression, 240Calcaneal fractures

diagnosis of, 248stress, 240, 244

Calcaneal heel pad, 239Carpal tunnel pain

description of, 102to thumb, 113

Carpal tunnel syndromegrading of, 100nerve conduction velocity testing for, 95summary of, 96, 114symptoms of, 84thumb pathology secondary to, 102Tinel sign for, 78, 88, 95, 106, 113, 123

Carpometacarpal jointcompression of, 87osteoarthritis of, 94, 107–108, 114, 117

Cauda equina syndrome, 150, 159–160, 170Cellulitis, 276Cervical osteoarthritis

description of, 2examination for, 8, 14lateral view of neck evaluation, 8passive rotation of neck evaluations, 8symptoms of, 2

Cervical radiculopathyclassification of, 18diagnosis of, 9differential diagnosis of, 1


Cervical radiculopathy (Continued)examination for, 9–10, 14herniated nucleus pulposus as cause of, 2magnetic resonance imaging of, 10manual cervical traction for, 9oblique views of the neck for, 10pain associated with, 5, 9prognosis for, 18radiographs for, 6referred pain to upper back from, 64signs of, 2Spurling maneuver, 5, 9

Cervical spinecross-table lateral x-ray of, 17–18magnetic resonance imaging of, 43motor testing of, 16oblique view of, 64palpation of, 16sensory testing of, 15spinous processes of, 16x-ray series for, 18

Cervical straindescription of, 2differential diagnosis of, 1examination for, 14reactive, 6, 17signs and symptoms of, 2

Cervical traction, manual, 9Charcot fracture, 273Chest

examination of, 138–139one-minute screening examination of,

139–142shoulder pain referred from, 44

Chest compression test, 55, 61, 140Chest pain

description of, 138epidemic pleurodynia, 138, 141, 146, 148symptoms of, 138xiphodynia, 138, 147–148

Chest trauma, 138Chest wall

examination of, 139–142expansion assessments, 141

Chest x-rays, for rib fractures, 61Claudication, 189Clavicle fractures, 46, 48Coccydynia, 168, 170Collateral ligaments, of knee

lateral, 211, 217medial, 210

Colles fracturesdescription of, 83displaced, 98foreshortened, 98nondisplaced, 97

Compression fracturesof lumbosacral spine, 150–151, 165, 170of thoracic spine, 62–63, 65

Computed tomographycauda equina syndrome evaluations, 159low back pain referred from abdomen, 169lumbar radiculopathy evaluations, 158, 191,

216lumbosacral osteoarthritis evaluations, 161

Costochondral junction palpation, 140, 143Costochondritis, 143, 148Costothoracic syndrome, 20Cross-table lateral x-ray of cervical spine, 17–18Cubital tunnel syndrome, 78–79Cysts

Baker’s, 197, 213, 217, 221dorsal ganglion, 92, 96mucinoid, of distal interphalangeal joint,

132–133

Cysts (Continued)tendon, 128tenosynovial, 133

DDe Quervain’s tenosynovitis

description of, 82, 102, 114local anesthetic block for, 110, 117radial styloid palpation for, 87, 94, 103,

105, 110Diffuse idiopathic skeletal hyperostosis,

161Dislocation

elbow, 80hip joint, 193interphalangeal joint, 116metacarpophalangeal joint, 116patellar, 217perilunate, 99proximal interphalangeal joint, 135shoulder, 46

Distal femur fracture, 218Distal humeral fractures, 81Distal interphalangeal joint

arthritis of, 133bony enlargement of, 124inspection of, 122mucinoid cyst of, 132–133

Distal radius fractures, 83Doppler ultrasound, for aortoiliac vascular

occlusive disease, 189Dorsal bunion, 268Dorsal ganglion cyst, 92, 96Dorsokyphotic posture, 3Dorsotenosynovitis

of foot, 267, 271, 276of wrist, 82, 93, 96

Draftsman’s elbow. See Olecranon bursitisDuck waddle, ability to, 199Dupuytren’s contracture, 119, 129, 133,

136Dynamometry, 104, 121

EElbow

aspiration of, 76differential diagnosis, 66dislocation of, 80examination of, 68flexion of

isometrically resisted, 77range of motion testing, 68

fractures of, 80–81lateral x-ray of, 74–75one-minute screening examination of,

68–70range of motion testing

in extension, 68in flexion, 68passive, 75in pronation, 69in supination, 69

swelling of, 67symptoms involving, 66

Elbow painanterior, 67, 68description of, 67differential diagnosis, 68lateral, 67, 68medial, 67, 68posterior, 67, 68referred, 67, 68, 79

Electromyographylumbosacral spine conditions, 155upper extremity, 13, 14

Epicondylitislateral

description of, 67, 81local anesthetic block for, 71summary of, 79tests for, 69

medialdescription of, 67, 81local anesthetic block for, 72summary of, 79tests for, 69

Epidemic pleurodynia, 138, 141, 146, 148Epidural process, 166, 170Examination

of ankle, 223–224of chest, 138–139of elbow, 68of foot, 251–252of hand, 119–120of hip joint, 174of knee, 197–198of neck, 2–3of shoulder, 21of thumb, 102–103of upper back, 52

Extensor tendonsof foot, 264of hand, 119, 131

FFemur

distal, fracture of, 218metastatic disease of, 188, 192

Fibular fracturesavulsion, 245description of, 220displaced, 246nondisplaced, 246

Finger(s)mallet, 119–120, 131, 133passive extension of, 127trigger, 127, 133, 136

Flexor digitorum profundus tendon rupture,135–136

Flexor tendonsof hand, 119of thumb, 105

Footaccessory bones of, 276arch of

description of, 251, 254inspection of, 269palpation of, 269

description of, 251dorsum of

description of, 251–252swelling of, 267

examination of, 251–252extensor tendons of, 264fractures of, 272–275inspection of, 256, 258, 262, 268one-minute screening examination of,

252–255posteroanterior x-ray of, 262referred pain to, 251sesamoid view of, 260swelling of, 253, 266x-rays of, 256, 268

Foot paindifferential diagnosis, 252dorsal swelling associated with, 251

Forearmgrip strength measurements, 85–86strength assessments of, 86

Forestier’s disease, 161

INDEX 297

Fracturesankle, 245–249calcaneal, 240, 244, 248Charcot, 273clavicle, 46, 48Colles, 83, 97–98compression

of lumbosacral spine, 150–151, 165, 170of thoracic spine, 62–63, 65

distal femur, 218distal humeral, 81distal phalanx, 136distal radius, 83, 97elbow, 67, 80–81fibular

avulsion, 245description of, 220displaced, 246nondisplaced, 246

foot, 272–275great toe, 274greater tubercle, 47hand, 134–136hip

occult, 173, 187, 192types of, 193–194

humeral, 46–47, 81knee, 218–220march, 266metacarpal base, 115metatarsal base, 248midtarsal, 272navicular, 96, 98neuropathic, 273nondisplaced, 81patella, 218pelvic, 193proximal tibial, 218radial head, 80rib, 61–62, 65sesamoid bone, 274shoulder, 46–48spinal column, 51talus, 247, 249thumb, 102, 115–117tibial

displaced, 247of shaft, 219stress, 220

toe, 274–275tuff, 115ulnar, 81vertebral, 14wrist, 97–99

Frozen shoulderApley scratch sign, 22, 31description of, 20, 49examination for, 31–32, 45glenohumeral joint arthrography for, 32tests for, 31–32

GGait, 152, 175, 198Gamekeeper’s thumb

diagnosis of, 112, 114, 117symptoms of, 103

Glenohumeral jointabduction of, 22anterior swelling of, 39Apley scratch sign, 22, 31arthrography of, 32differential diagnosis, 19osteoarthritis of, 20, 39–40, 45rotation of, 22swelling of, 39touchdown sign, 22

Gluteus medius bursa palpation, 177Gluteus medius bursitis

description of, 173, 194diagnosis of, 180–181, 192

Golfer’s elbow. See Medial epicondylitisGout, 258–259, 271Great toe

fractures of, 274local plantar tenderness of, 260osteoarthritis of, 276

Greater occipital nervefocal tenderness of, 5palpation of, 11

Greater occipital neuralgiadescription of, 2diagnosis of, 14focal tenderness, 5headache associated with, 11local anesthetic block for, 11, 14

Greater trochanteric process, 179Greater tubercle fracture, 47Grip strength measurements

dynamometry for, 104, 121of hand, 104, 120–121of thumb, 104of wrist, 85–86

HHallux rigidus, 257, 271Hallux valgus, 256Hammer toe, 251, 264, 271, 276Hand

closing of, 103differential diagnosis, 118Dupuytren’s contracture of, 119, 129, 133,

136examination of, 119–120extensor tendons of, 119, 131flexor tendons of

description of, 119local anesthetic block over, 127

fractures of, 134–136grasping assessments, 120grip strength assessments, 120–121one-minute screening examination of,

120–123opening of, 103osteoarthritis of, 119, 124, 133range of motion testing, 126rheumatoid arthritis of, 119, 125–126, 136small joints of, 122x-rays of, 124–125

Hand paindiffuse, 119symptoms of, 119

Headposture of, 3trauma evaluations, 15–18

Headachecervical pain and, 2greater occipital neuralgia and, 11

Heelplantar, 223, 224posterior, 227

Heel pad syndrome, 239, 244Heel-to-buttock measurement, 199, 206Hemarthrosis, 221Herniated nucleus pulposus

cervical radiculopathy caused by, 2magnetic resonance imaging of, 43

“High-riding humeral head” sign, 30, 33Hip

acute arthritis of, 183–184, 192aspiration of, 184avascular necrosis of, 186, 192characteristics of, 173

Hip (Continued)description of, 173dislocation of, 193examination of, 174external rotation testing, 182–183, 187–188femur, metastatic disease of, 188, 192internal rotation testing, 182–183, 187–188one-minute screening examination of,

174–178osteoarthritis of, 173, 181–182, 192range of motion testing, 176, 186referred pain, 173, 198

Hip fracturesoccult, 173, 187, 192types of, 193–194

Hip painaortoiliac vascular occlusive disease as cause

of, 189, 192description of, 173–174from lumbosacral spine, 190

Humeral fractures, 46–47, 81

IIliopectineal bursitis

description of, 173Iliotibial band syndrome, 215, 217Impingement syndrome

description of, 49examination for, 21, 45lidocaine injection test for, 28passive painful arc maneuver for, 24, 28symptoms of, 20

Infraspinatus tendoninflammation of, 20isometric testing of, 29

Inspectionof distal interphalangeal joint, 122of dorsal ganglion, 92of foot, 256, 258, 262, 268of metacarpophalangeal joint, 122of olecranon bursa, 70, 73of palm, 122, 129of proximal interphalangeal joint, 122of thumb, 105of upper back, 53

Intercostal musclesepidemic pleurodynia of, 146palpation of, 141

Intercostal nerve block, for rib fractures, 62Intercostal space, 141, 146Interphalangeal joint

arthritis of, 109dislocation of, 116distal

bony enlargement of, 124inspection of, 122mucinoid cyst of, 132

x-rays of, 109Intra-articular anesthetic block

for ankle arthritis, 232for subtalar arthritis, 233

Ischiogluteal bursitis, 173Isometric testing, of shoulder

description of, 23infraspinatus tendon, 29supraspinatus tendon, 29

JJoint. See specific joint

KKienböck’s disease, 82Knee

anatomy of, 196anterior cruciate ligament injury, 212aspiration of, 206


Knee (Continued)differential diagnosis, 195examination of, 197–198fractures of, 218–220joint lines of, 200, 204lateral femoral condyle, 215ligaments of

anatomy of, 196anterior cruciate, 212, 217injury to, 210–212lateral collateral, 211, 217medial collateral, 210, 217, 221

meniscal tears of, 197–198, 213–214, 217,221

one-minute screening examination of,198–202

osteoarthritis ofdescription of, 197, 221lateral compartment, 207–208, 217medial compartment, 204–205, 217, 221

Knee effusion, 205–206, 217, 221Knee pain

age-related variations in, 196anterior, 196–197differential diagnosis, 196, 197lateral, 197medial, 196referred, 196, 198, 216symptoms of, 196–197

LLateral collateral ligament injury, 211, 217Lateral compartment osteoarthritis, 207–208,

217Lateral elbow pain, 67, 68Lateral epicondyle palpation, 69, 71Lateral epicondylitis


Lateral femoral condyle, 215Lateral joint line tenderness, 208Lateral x-ray

of ankle, 237of elbow, 74–75

Leriche’s syndrome, 189Levator scapula

description of, 51palpation of, 57

Lidocaine injection testfor impingement syndrome, 28for rotator cuff tendonitis, 31

Local anesthetic blocksdiagnostic uses of

acromioclavicular osteoarthritis and sepa-ration, 38

anserine bursitis, 209carpal tunnel syndrome, 113coccydynia, 168costochondritis, 143de Quervain’s tenosynovitis, 110, 117gamekeeper’s thumb, 112, 114, 117gluteus medius bursitis, 181greater occipital neuralgia, 11, 14iliotibial band syndrome, 215intercostal muscles, 146lateral collateral ligament injury, 211, 217lateral epicondylitis, 71low back strain, 157medial collateral ligament injury, 210, 217medial epicondylitis, 72meralgia paresthetica, 185metacarpophalangeal joint arthritis, 130Morton’s neuroma, 265, 271paraspinal muscles, 157

Local anesthetic blocks (Continued)peroneus tenosynovitis, 242plantar fasciitis, 238posterior tibial tenosynovitis, 241pre-Achilles bursitis, 235prebunion bursitis, 258, 271radiocarpal joint arthritis, 91reactive cervical strain, 6retrocalcaneal bursitis, 236rhomboids, 58rib fracture, 144sacrococcygeal junction, 168sacroiliac joint conditions, 167, 190sternoclavicular joint arthritis, 145subscapular bursa, 59subscapular bursitis, 42, 65temporomandibular joint syndrome, 12,

14trapezius, 58trigger finger, 127trigger thumb, 111trochanteric bursitis, 179xiphodynia, 147

intramuscular, for reactive cervical strain, 6Low back pain

differential diagnosis, 151diffuse, 150focal, 150referred, 169structural causes of, 150

Low back strain, 150, 155–157Lower extremity. See also specific anatomy

neurologic examination of, 191pulse taking, 189

Lumbar radiculopathydescription of, 150, 170–171diagnosis of, 157–158, 191, 216foot symptoms caused by, 251

Lumbosacral spinecompression fractures of, 150–151, 165differential diagnosis, 149epidural process of, 166examination of, 151functional stiffness of, 160hip pain referred from, 190one-minute screening examination of,

151–155osteoarthritis of, 160–161, 170Schober test of, 152, 156, 162scoliosis of. See Scoliosisspinous processes of, 164stenosis of, 2, 161–162, 170strain of, 150, 155–157, 170

MMagnetic resonance imaging

Achilles tendon rupture, 234ankle conditions, 228anterior cruciate ligament injury, 212avascular necrosis of hip joint, 186cervical radiculopathy, 10cervical spine, 43chest conditions, 142compression fractures

of lumbosacral spine, 165of thoracic spine, 63

elbow conditions, 70epidural process, 166, 170hip conditions, 178knee conditions, 202lumbosacral spine conditions, 155meniscal tears, 214neck conditions, 6occult hip fracture, 187shoulder, 34shoulder conditions, 27

Magnetic resonance imaging (Continued)spinal stenosis, 162upper back conditions, 56wrist conditions, 88

Mallet finger, 119–120, 131, 133Manual cervical traction, 9March fracture, 266McMurray maneuver, 214, 221Medial collateral ligament injury, 210, 217, 221Medial compartment osteoarthritis, 204–205,

217, 221Medial elbow pain, 67, 68Medial epicondyle palpation, 69, 72Medial epicondylitis


Meniscal tears, 197–198, 213–214, 217, 221Meralgia paresthetica, 173, 185, 194Metacarpal base fracture, 115Metacarpophalangeal joint

dislocation of, 116inspection of, 122lateral collateral ligament of, avulsion of,

117lateral lines of, 109osteoarthritis of, 102, 109, 114pain at, 103, 119–120squeeze sign of, 126swelling of, 130traumatic arthritis of, 130, 133

Metastatic disease, of femur, 188, 192Metatarsal fractures

base, 248fifth, 273first, 273fourth, 273second, 273stress, 266, 271third, 273

Metatarsal pain, 266Metatarsalgia, 251, 263, 271, 276Metatarsophalangeal joint

alignment of, 252–253aspiration of, for gout diagnosis, 259conditions that affect, 251metatarsalgia of, 263, 276squeeze sign of, 254–255, 263, 265

Midtarsal fractures, 272Morton’s neuroma, 251, 265, 271Motor testing of neck, 16Mucinoid cyst of distal interphalangeal joint,

132–133Multidirectional instability of shoulder, 41, 45

NNavicular

avascular necrosis of, 99fracture of, 96, 98

Neckdifferential diagnosis, 1examination of, 2–3general movement of, 3lateral bending of, 2–3lateral view of, 8oblique views of, 10one-minute screening examination of

management options, 6maneuvers, 3–6

passive rotation of, 4, 8posture of, 3rotation of, 2–3sensory testing of, 15supporting muscles of, 3, 4trauma evaluations, 15–18

INDEX 299

Neck osteoarthritisdescription of, 2examination for, 8, 14lateral view of neck evaluation, 8passive rotation of neck evaluations, 8symptoms of, 2

Neck paindescription of, 2treatment of, 6

Neck stiffnessdescription of, 2treatment of, 6

Nerve conduction velocity testingcarpal tunnel syndrome evaluations, 95cubital tunnel syndrome evaluations, 78hand conditions, 122tarsal tunnel syndrome evaluations, 243ulnar neuropathy evaluations, 78

Neuropathic fracture, 273Nuclear bone scan, for calcaneal stress fracture,

240

OOblique view

of cervical spine, 64of neck, 10

Occult hip fractures, 173, 187, 192Olecranon bursa

inspection and palpation of, 70, 73needle aspiration of, 73

Olecranon bursitisacute, 73chronic, 73description of, 67needle aspiration for, 73summary of, 79

Os trigonum syndrome, 237, 244Osgood-Schlatter epiphysitis, 196Osteoarthritic flare, 25Osteoarthritis

acromioclavicular joint, 20, 25, 37–38, 45, 49ankle, 232–233carpometacarpal joint, 94, 107–108, 113, 117cervical

description of, 2examination for, 8, 14lateral view of neck evaluation, 8passive rotation of neck evaluations, 8symptoms of, 2

glenohumeral joint, 20, 39–40, 45great toe, 276hand, 119, 124, 133hip joint, 173, 181–182, 192knee

lateral compartment, 207–208medial compartment, 204–205

lumbosacral spine, 160–161, 170metacarpophalangeal joint, 102, 109sternoclavicular joint, 45, 145, 148ulnarhumeral joint, 75–76

Osteochondritis dissecans, 219Osteoporosis, 65

PPain

ankle, 223, 224carpal tunnel, 102cervical radiculopathy, 5, 9chest, 138, 141, 146–148elbow, 67, 68, 79foot, 251, 252hand, 119hip, 173–174, 189–190, 192knee, 196–198, 216low back, 150–151, 169metacarpophalangeal joint, 103, 119–120

Pain (Continued)neck, 2, 6periscapular, 65popliteal, 197referred. See Referred painshoulder, 20, 21, 43–44sternoclavicular joint, 138thumb, 101–102, 113upper back, 65wrist, 82–83

Palm of hand, 122, 129Palpation

of abdomen, 169of acromioclavicular joint, 25, 37of arch of foot, 269of bicipital groove, 35of cervical spine, 16of costochondral junction, 140, 143of flexor tendons

of hand, 128of thumb, 105, 111

of gluteus medius bursa, 177of greater occipital nerve, 11of greater trochanteric process, 179of intercostal muscles, 141of intercostal space, 146of lateral epicondyle, 69, 71of levator scapula, 57of medial epicondyle, 69, 72of olecranon bursa, 70, 73of paraspinal muscles, 17, 153of plantar heel, 227of pre-Achilles bursa, 235of proximal interphalangeal joint, 125of radial styloid, 87, 94, 103, 105, 110of rhomboids, 57of sacrococcygeal junction, 168of sacroiliac joint, 154, 167of spinous processes, 62, 164of sternochondral junction, 140, 143of sternoclavicular joint, 26of subacromial space, 25of subscapular bursa, 26, 42, 54, 59of superior trochanteric process, 180of temporomandibular joint, 6, 12of trapezius, 4, 7, 54, 57of trochanteric bursa, 177of xiphoid process, 147

Paraspinal muscleslocal anesthetic block of, 157palpation of, 17, 153spasm of, 60

Paravertebral joints, 8Passive painful arc maneuver, 24, 28Passive rotation of neck, 4, 8Passive stretching of ankle, 226, 229Patella

fracture of, 218subluxation of, 221

Patellar compression, 200, 203Patellar tendonitis, 221Patellofemoral syndrome, 197, 202–203, 217Pelvis

fracture of, 193weight-bearing anteroposterior x-ray of, 152

Perilunate dislocation, 99Periscapular pain, 65Peroneus tenosynovitis, 242, 244Pes cavus, 251, 269, 271Pes planovalgus, 251Pes planus, 251, 269, 271Phalanges

distal, 115, 136fractures of, 115, 134middle, 134proximal, 134

Plantar fasciitis, 223, 238, 244Plantar heel

pain of, 223, 224palpation of, 227

Pleurodynia, epidemic, 138, 141, 146, 148Popliteal fossa, 213Popliteal pain, 197Posterior tibial tenosynovitis, 241, 244Posture

dorsokyphotic, 3of head, 3of neck, 3

Pre-Achilles bursa, 235Pre-Achilles bursitis, 235, 244, 249Prebunion bursitis, 258, 271, 276Prepatellar bursa, 201, 207Prepatellar bursitis, 207, 217Pronator teres syndrome, 95Proximal interphalangeal joint

dislocation of, 135flexor digitorum profundus tendon rupture,

135–136inspection of, 122palpation of, 125

Proximal tibial fracture, 218Puncture

of mucinous cysts, 132of tendon cysts, 128

QQ-angle, 203Quadriceps strength testing, 199

RRadial head fractures, 80Radial styloid palpation, 87, 94, 103, 105, 110Radiculopathy

cervicalclassification of, 18diagnosis of, 9differential diagnosis of, 1examination for, 9–10, 14herniated nucleus pulposus as cause of, 2magnetic resonance imaging of, 10manual cervical traction for, 9oblique views of the neck for, 10pain associated with, 5, 9prognosis for, 18radiographs for, 6referred pain to upper back from, 64signs of, 2Spurling maneuver, 5, 9

lumbardescription of, 150, 170–171diagnosis of, 157–158, 191, 216foot symptoms caused by, 251

Radiocarpal jointarthritis of, 90–91, 96dorsal swelling and tenderness of, 90line tenderness evaluations, 89local anesthetic block or aspiration of, 91range of motion testing, 90

Radiographs. See X-raysRadiohumeral joint arthritis, 76, 79Range of motion testing

of ankle, 226of elbow

in extension, 68in flexion, 68passive, 75in pronation, 69in supination, 69

of hand, 126of hip joint, 176, 186of radiocarpal joint, 90of wrist, 84–85


Reactive cervical strain, 6, 17Rectal sphincter tone, 159Referred pain

to ankle, 222from cervical radiculopathy, 64to elbow, 67, 68, 79to hip joint, 173, 190to knee, 196, 198, 216to low back, 169from lumbosacral spine, 190to neck, 1–2from sacroiliac joint, 190to shoulder, 19, 43–44to thumb, 113to upper back, 50–51, 64to wrist, 82

Reflex sympathetic dystrophy, 270Reiter’s disease, 145Retrocalcaneal bursitis, 223, 236, 244Retrocalcaneal space, 236Rheumatoid arthritis

of ankle, 232–233of hand, 125–126, 136of radiohumeral joint, 76, 79of ulnarhumeral joint, 76

Rhomboidsdescription of, 51local anesthetic blocks in, 58palpation of, 57

Rib contusion, 61–62, 65, 148Rib fracture

description of, 61–62, 65, 148nondisplaced, 144

Rotationhip joint, 182–183, 187–188passive, 4

Rotator cuffarthrography of, 34differential diagnosis of, 19high-riding humeral head sign, 30, 33impingement syndrome. See Impingement

syndrometear of, 20, 33–34, 49tendonitis of, 29–30, 45, 49weakness of, 33

SSacrococcygeal junction, 168Sacroiliac joint

palpation of, 154referred pain from

to hip, 190to knee, 198

strain of, 150, 167, 170Sacroiliitis, 150, 154, 167, 170Schober test, 152, 156, 162Sciatica, 150, 157, 171Scoliosis

anteroposterior spine x-ray for, 60, 65, 163description of, 170height measurements for assessing, 55, 60, 163

Sensory testingof anterolateral thigh, 185of cervical spine, 15of neck, 15

Sesamoid bone fractures, 274Sesamoiditis, 260, 271Shoulder. See also Acromioclavicular joint;

Glenohumeral joint; Rotator cuffanatomy of, 20anterior, 20crepitation of, 41differential diagnosis, 19dislocation of, 46examination of, 21fractures of, 46–48

Shoulder (Continued)magnetic resonance imaging of, 34one-minute screening examination of

acromioclavicular joint palpation, 25Apley scratch sign, 22, 31isometric testing, 23management options, 27maneuvers for, 21–26passive painful arc maneuver, 24sternoclavicular joint palpation, 24subscapular bursa palpation, 26sulcus sign, 24, 41touchdown sign, 22weighted touchdown sign, 23

subluxation of, 41trauma to, 20

Shoulder instabilityapprehension test for, 41differential diagnosis, 19multidirectional, 41, 45sulcus sign for, 41

Shoulder painanterior, 20, 21description of, 20posterior, 21referred, 43–44

Spinal column fractures, 51Spinal stenosis, 2, 150, 161–162, 170Spine. See Cervical spine; Lumbosacral spine;

Thoracic spineSpinous processes

of lumbosacral spine, 164, 166palpation of, 62, 164of vertebral bodies, 62, 153

Spondylolisthesis, 164, 170Sprain

ankledescription of, 223diagnosis of, 229–231, 244instability associated with, 230

wrist, 89, 96Spurling maneuver, 5, 9Squat, 175, 198Squeeze sign

of metacarpophalangeal joint, 126of metatarsophalangeal joint, 254–255, 263,

265Sternal injury, 148Sternochondral junction palpation, 140, 143Sternochondritis, 143, 148Sternoclavicular joint

differential diagnosis, 19osteoarthritis of, 45, 145, 148palpation of, 26swelling of, 148

Sternoclavicular joint pain, 138Straight leg raise maneuver, 153, 158, 171, 177,

216Strain

cervicaldescription of, 2differential diagnosis of, 1examination for, 14reactive, 6, 17signs and symptoms of, 2

lumbosacral, 150, 155–157, 170sacroiliac, 150, 167trapezius, 57upper back, 51, 65

Strength testinggrip

dynamometry for, 104, 121of hand, 104, 120–121of thumb, 104of wrist, 85–86

quadriceps, 199

Stress fracturescalcaneal, 240metatarsal, 266, 271

Subacromial bursitischronic, 20description of, 20

Subacromial impingementdescription of, 20passive painful arc maneuver for, 24, 28

Subacromial spacenarrowed, 30, 33palpation of, 25width of, 30

Subluxationpatellar, 221shoulder, 41

Subscapular bursadescription of, 20palpation of, 26, 54, 59

Subscapular bursitis, 42, 45, 51, 59, 65Subtalar arthritis, 223, 233, 244Sulcus sign, 24, 41Superior trochanteric process, 180Supraspinatus tendon

inflammation of, 20isometric testing of, 29magnetic resonance imaging of, 34

Swellingof elbow, 67of foot, 253, 266of glenohumeral joint, 39of lateral ligament of ankle, 229of metacarpophalangeal joint, 130of radiocarpal joint, 90of sternoclavicular joint, 148of wrist, 83–84

TTalus fracture, 247, 249Tarsal tunnel syndrome

description of, 222diagnosis of, 244foot symptoms caused by, 251nerve conduction velocity testing for, 243Tinel sign for, 228, 243

Temporomandibular joint, 6, 12Temporomandibular joint syndrome, 12, 14Tendon cysts, 128Tendonitis

Achilles, 223, 234, 244, 249bicipital, 35–36, 45rotator cuff, 29–30, 45, 49

Tennis elbow. See Lateral epicondylitisTenosynovial cyst, 133Tenosynovitis

de Quervain’sdescription of, 82, 102, 114local anesthetic block for, 110, 117radial styloid palpation for, 87, 94, 103,

105, 110dorsotenosynovitis, 82, 93, 96, 267, 271,

276peroneus, 242, 244posterior tibial, 241, 244

Third-degree separation, of acromioclavicularjoint, 39, 45

Thoracic outlet syndromeAdson maneuver for, 13, 14diagnosis of, 13differential diagnosis of, 1upper extremity electromyography

evaluations, 13, 14Thoracic spine

arthritis of, 51compression fractures of, 62–63, 65radiculopathy of, 50

INDEX 301

Thumbbase of, compression of, 94, 107differential diagnosis, 101–102examination of, 102–103flexor tendons of, 105, 111fracture of, 102fractures of, 115–117gamekeeper’s, 103, 112, 114, 117grip strength measurements of, 104inspection of, 105ligament injuries of, 102one-minute screening examination of,

103–107trigger, 111, 114

Thumb paindifferential diagnosis, 101–102referred, 113symptoms of, 102

Tibial fracturedisplaced, 247of shaft, 219stress, 220

Tinel signfor carpal tunnel syndrome, 78, 88, 95, 106,

113, 123for tarsal tunnel syndrome, 228, 241

Toe(s)fractures of, 275hammer, 251, 264, 271, 276Morton’s neuroma, 251, 265, 271turf, 261

Torticollis, 3, 14Touchdown sign, 22

weighted, 23Trapezius

function of, 6local intramuscular anesthetic block of,

6, 58palpation of, 4, 7, 54, 57spasm of, 18strain of, 57superior division of, 51upper portion of, 4

Traumaankle, 222chest, 138head, 15–18neck, 15–18shoulder, 20

Traumatic arthritis of metacarpophalangealjoint, 130, 133

Triangular cartilage injury, 96Triceps insertionitis, 74, 79Trigger finger, 127, 133, 136Trigger thumb, 111, 114

Trochanteric bursa palpation, 177Trochanteric bursitis

description of, 173, 192diagnosis of, 178–179referred pain from, 194

Tuff fracture, 115Turf toe, 261

UUlnar fractures, 81Ulnar neuropathy, 78Ulnarhumeral joint

arthritis of, 75–76passive range of motion testing, 75rheumatoid arthritis of, 76

Upper backbreathing pattern evaluations, 53differential diagnosis, 50examination of, 52general movement of, 52inspection of, 53muscular strain of, 51, 65one-minute screening examination of

breathing patterns, 53chest compression test, 55, 61height measurements, 55, 60management options, 56maneuvers for, 52–56subscapular bursa palpation, 54trapezius palpation, 54

pain of, 65Upper body movement, 139Upper extremity. See also specific anatomy

electromyography of, 13, 14neurologic impairment of, 2

VValgus stress test

for gamekeeper’s thumb, 112for medial collateral ligament injury, 210

Vertebral bodiesof neck, 18palpation of, 56spinous processes of, 62, 153of upper back, 56, 62–63

Vertebral bony lesions, 62–63, 65Vertebral column injury, 18Vertebral fracture, 14Volar ganglia, 100

WWeight bearing during walking, 225, 253Weight-bearing x-rays

of knee, 205, 208of pelvis, 152

Weighted touchdown sign, 23Wink sign, 159Wrist

differential diagnosis, 82dorsotenosynovitis of, 82, 93, 96dorsum of, 87examination of, 84fractures of, 97–99grip strength measurements, 85–86one-minute screening examination of,

84–88range of motion testing of, 84–85stiffness of, 84–85strength assessments of, 86swelling of, 83–84synovial fluid, 100x-rays of, 89

Wrist paindifferential diagnosis, 83dorsal, 83referred, 82types of, 83

Wrist sprain, 89, 96

XXiphodynia, 138, 147–148Xiphoid process, 147X-rays. See also specific x-ray

avascular necrosis of hip joint evaluations,186

bilateral sunrise, 203calcaneal stress fracture, 240of carpometacarpal joint, 108cervical radiculopathy evaluations, 6of foot, 256, 268of hallux rigidus, 257of hands, 124–125of interphalangeal joint, 109of mallet finger, 131of metastatic disease of femur, 188metatarsal stress fracture, 266of radiocarpal joint, 91for reflex sympathetic dystrophy, 270spondylolisthesis evaluations, 164subacromial width evaluations, 30weight-bearing

of knee, 205, 208of pelvis, 152

of wrist, 89

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