Neuromusculoskeletal diagnosis

I. Wrist

A. Instability disorders

1. Scapholunate dissociation

  • Classic presentation: Radial or dorsal pain following a fall on an outstretched hand (FOOSH)
  • Cause:
    • Fall onto thenar eminence: wrist forced into hyperextension, ulnar deviation, intercarpal supination→forces capitates between scaphoid and lunate
    • Tearing or stretching of scapholunate interosseous and radioscaphoid ligaments→instability
  • Evaluation:
    • Watson’s test: arm relaxed, passively ulnar deviate wrist, press distal pole posteriorly, radially deviate wrist→painful pop or click as proximal pole subluxates dorsally
    • Radiographic Evaluation:
      • AP, lateral, oblique, AP clenched-first view, lateral view (flexion and extension)
      • AP or PA: 3 mm or greater space between lunate and scaphoid (“Terry Thomas” or “David Letterman” sign = gapping teeth)
        • Signet ring sign: vertical orientation of scaphoid that creates cortical overlap
      • Lateral View: DISI pattern visible
        • Normal angle of scaphoid: between 30° and 60°
        • Dissociation: angle > 65-70°
  • Management: Surgery

2. Triquetrolunate dissociation

  • Classic presentation: Fall: palmar-flexed or hyperpronated wrist
  • Cause: Stretching or disruption of lunotriquetral ligaments→palmar subluxation of lunate
  • Evaluation:
    • Ballottement test: stabilize lunate or triquetrum and shear: positive = painful pop
    • Radiographic Evaluation:
      • Static instability: PISI (aka VISI) seen on lateral view
      • PISI pattern = palmar subluxation of lunate and scaphoid with dorsiflexed triquetrum
    • Fluroscopic Evaluation or Arthrogram
  • Management:
    • Ballottment test: positive and radiographs: negative = immobilization in long arm cast 6 to 8 weeks (wrist in ulnar deviation and dorsiflexion)
    • Radiographic evidence of static instability:
      • Surgery
      • Reposition lunate and scaphoid followed by immobilization

3. Triquetrohamate instability (midcarpal)

  • Classic presentation: Fall or blow: medial side of hand with hyperpronation (Some without traumatic event)
  • Cause: Ligamentous tearing: disrupts osseous coupling between hamate and triquetrum
  • Evaluation:
    • Passive or active pronation coupled with ulnar deviation: painful click
      • DDx: TFC damage, lunotriquetral ligaments tears, distal radioulnar subluxation, axial compression
    • Radiographic Evaluation: normal
      • Static instability: DISI pattern
    • Videofluoroscopic evaluation:
      • Most sensitive
      • Radial deviation: reveals sudden movement of proximal carpal row from normal PISI pattern
      • DISI pattern: near end-range of ulnar deviation
  • Management:
    • Immobilization for 6 weeks
    • Surgery: if immobilization is ineffective for reducing instability or pain

4. Triangular fibrocartilage injury

  • Classic presentation:
    • Pain: ulnar side of wrist, worse with pronation and supination
    • FOOSH or no trauma
  • Cause:
    • Perforations (traumatic and degenerative) or avulsions
    • Degenerative: 3rd decade
    • Poor blood supply
    • Ulnar positive variance: compression and thinning of TFC
  • Evaluation:
    • TFC: fibrocartilagenous structure at distal end of ulna
      • Part of complex that supports ulnar side of wrist
    • Differentiate damage to distal radioulnar joint (DRUJ) and TFC:
      • stabilize radius and ulna by compressing together proximal to DRUJ
      • TFC involved: if passive movement of forearm into pronation and supination is uneventful
      • TFC damaged: pain and crepitis with ulnar deviation, axial loading, and shearing distal to DRUJ
    • Radiographic Evaluation: determines positive ulnar variance
      • Standardization: PA film at 90° of elbow and shoulder flexion with hand flat as possible
      • Line drawn perpendicularly across distal end of radius = distal ulna
    • Arthrogram or MRI: refer to confirm TFC damage
  • Management:
    • Immobilize wrist in neutral for several weeks
    • Failure to resolve: arthroscopic evaluation and repair (resection of distal ulna)

B. Tendinitis/tendinosis

1. DeQuervain’s tenosynovitis

  • Classic presentation:
    • Radial wrist pain
    • History: forceful gripping with ulnar deviation or repetitive use of thumb
  • Cause:
    • Stenosing tenosynovitis of abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
    • Chronic microtrauma to tenosynovium or sheath
  • Evaluation:
    • Resisted thumb extension with wrist in radial deviation: pain
    • Finkelstein test (patient grasps thumb with same side fingers and examiner passively deviates wrist ulnarly): tenderness 1⁄2 inch proximal to radial styloid
  • Management:
    • Modification, ultrasound, NSAIDs initially
    • Failure to improve in 2 to 3 weeks: thumb spica for another 2 to 3 weeks
    • If ineffective: refer or local steroid injection (surgery rarely needed)

2. Intersection syndrome

  • Classic presentation:
    • Pain and crepitis: 2 inches above wrist on dorsoradial aspect
    • History of repeated flexion/extension movement (occupational or sports activity)
  • Cause:
    • Inflammatory response and possible adventitial bursitis at crossing of two tendons over wrist extensors:
      • APL
      • EPB
      • Canoeists, weight lifters, recreational tennis players
  • Evaluation: Tenderness and swelling 4 to 6 cm proximal to Lister’s tubercle
  • Management:
    • Rest, NSAIDs, and ice
    • Myofascial release techniques applied proximal to tendon crossing
    • Unsuccessful: splinting for 2 weeks to enforce rest period
    • Prevention: modification or elimination of inciting activity

3. Other tendonopathies

  • Classic presentation:
    • Extensor pollicis longus tendinitis/tendinosis: drummers, racquet athletes, rheumatoid arthritis
    • Extensor indices proprius syndrome and extensor digiti minimi tendinitis/tendinosis: trauma and overuse
    • Extensor carpi ulnaris tendinitis/tendinosis:
      • Common tenosynovitis
      • Repetitive wrist movement: racquet sports, rowing, golf, baseball
      • Forced supination, flexion, and ulnar deviation:
        • Tendon sheath may rupture
        • Painful snapping over back of wrist
  • Cause:
  • Evaluation:
    • Palpation of tendon or its insertion is usually painful
    • Associated swelling
    • Full stretching of tendon or contraction in a stretched position: reproduces pain possible
  • Management:
    • Avoid inciting activity
    • Myofascial release of involved muscle
    • If ineffective: short period of soft cast immobilization
    • With RA: refer for medical management

C. Median nerve

1. Carpal tunnel syndrome

  • Classic presentation:
    • Pain and numbness/tingling: palmar surface of thumb and radial two and one half fingers
    • Worse at night
    • Clumsiness with precision gripping
  • Cause:
    • Direct external pressure on tunnel
    • Prolonged wrist use in full flexion or extension
    • Pressure in tunnel increases full flexion or extension
    • Fluid retention: pregnancy, RA, diabetes, connective tissue disorders
    • B vitamin deficiency
  • Evaluation:
    • Orthopedic Tests:
      • Phalen’s, Reverse Phalen’s, Tinel’s: variable responses
      • Pressure-provocative: more sensitive
        • Direct pressure applied with thumb over carpal tunnel
        • Pinch and grip strength: weaker on involved side
      • Thenar atrophy: chronic cases
      • Electrodiagnostic studies: conduction delay at wrist possible
  • Management:
    • Night splinting in extension or neutral
    • Avoid compressive maneuvers (typing)
    • B-complex vitamin
    • Adjust lunate

2. Pronator Syndrome

  • Classic presentation:
    • Volar forearm pain
    • No trauma
    • Repetitive pronation and wrist flexion: carpenters, assembly line workers, and weight lifters
  • Cause:
    • Compression:
      • Bicipital aponeurosis that connects with pronator teres
      • Two heads of the pronator teres: due to hypertrophy
      • Flexor digitorum superficialis by thickened fibrotic arch
      • Rare sites: Ligament of Struthers, median artery, bicipital tuberosity bursa
  • Evaluation:
    • Provocation with:
      • Resisted elbow flexion: lacertus fibrosus (or Ligament of Struthers)
      • Maximum elbow flexion: lacertus fibrosus (or Ligament of Struthers)
      • Resisted pronation: pronator teres compression (hypertrophy common)
      • Keeping elbow extended and wrist flexed: pronator teres compression (hypertrophy common)
      • Resisted middle finger flexion: flexor digitorum superficialis compression
    • Indentations in pronator teres: lacertus fibrosus involved
    • Direct pressure over pronator teres: reproduces symptoms
  • Management:
    • Myofascial release and/or rest
    • Unresponsive to MFR after 2 to 3 weeks: splinting for 2 to 3 weeks
    • Symptoms beyond 6 months: surgical exploration

3. Anterior interosseous syndrome

  • Classic presentation:
    • Anterior proximal forearm pain
    • Acute or single violent forearm muscle contraction
    • Repetitive activity
    • Associated weakness: pinch of thumb and index finger within 12-24 hours after onset of pain
  • Cause:
    • Compression: sites similar to those of pronator syndrome
    • Flexor digitorum superficialis or deep head of pronator teres: most common
    • Anterior interosseous nerve and motor branch of median nerve: compressed or entrapped
    • Stingers (acute stretch injuries to the brachial plexus)
    • After interscalene block
  • Evaluation:
    • Pinch tips of thumb and index together:
      • Inability
      • Results in pulp to pulp pinch
      • Weakness in flexor policis longus (FPL) and index finger flexor digitorum profundus (FDP)
    • Pronator quadratus: weak with resisted forearm pronation and full elbow flexion
    • Weakness of hand intrinsics: Martin-Gruber anastomosis
    • Electrodiagnostic studies: Gold standard with denervation of FPL and index finger FDP and pronator quadratus
  • Management:
    • Conservative: up to 8 weeks
      • Myofacial release, rest, and anti-inflammatory medication
    • Surgery: after 8 weeks

D. Ulnar nerve

1. Cubital tunnel syndrome

  • Classic presentation:
    • Medial forearm pain
    • Paresthesia into the ring and little finger
    • Activities that stretch elbow: throwing
  • Cause:
    • Stretch: valgus force to elbow
    • Compression:
      • Two heads of flexor carpi ulnaris
      • Osteophytes in cubital tunnel
      • Lipomas, ganglions, anomalous soft tissue structures (all less common)
    • Pressure increased with elbow flexion and wrist extension (threefold), and cocking (sixfold)
  • Evaluation:
    • Passive or resisted elbow flexion with elbow in maximally flexed position: reproduces symptoms
    • Tinel’s sign: variable and unreliable
    • Electrodiagnostic studies: rarely necessary, but help DDx other medial forearm pain syndromes
  • Management:
    • Conservative: rest, ice, anti-inflammatories
    • Entrapment at flexor carpi ulnaris: myofascial release
    • Night splinting of elbow: 45° flexion or neutral
    • Failure of conservative care: surgery

2. Tunnel of Guyon

  • Classic presentation: Numbness/tingling or pain in the fourth and fifth digits
  • Cause:
    • Osseofibrous tunnel formed by groove between pisiform and hook of hamate
    • Chronic compression: ulnar nerve dysfunction
    • Compression on handlebars (cyclist’s or handlebar palsy)
    • Vascular abnormalities
    • Fractures of hook of hamate 6. Ganglions
  • Evaluation:
    • Tinel’s or pressure at pisiform hamate area (distal and medial to pisiform): pain
    • Motor and Sensory findings: mixed due to compression at several areas
    • Sensory:
      • Abnormalities in 4th and 5th digits
      • Two-point discrimination: affected in 4th and 5th digits
    • 4. Motor:
      • Grip strength
      • Froment’s sign: weakness of adductor policis: grasping piece of paper, patient lexes distal thumb to compensate for weak adductor policis
    • Wartenberg’s sign: positive, patient cannot fully adduct all fingers
  • Management:
    • Protection with padding
    • Modification of inciting activity: reduce pressure to area (change in handlebar or bicycle position)
    • Neural deficit: refer to orthopedist for persistence for longer than a few weeks

E. Radial nerve

1. Radial tunnel syndrome:

  • Classic presentation: Dull aching pain over lateral forearm
  • Cause:
    • Entrapment of radial nerve at these sites: radial head, medial edge of ECRB, fan-shaped vascular arcade (arcade of Frohse), two heads of supinator muscle
    • RTC vs. PINS: clinical distinction: PIN = motor findings with no sensory deficits
  • Evaluation:
    • Tenderness distal to lateral epicondyle
    • Entrapment at ECRB: resisted middle finger extension with elbow extended
    • Entrapment at radial head: elbow flexion
    • Entrapment at supinator muscle: resisted, repeated supination with the forearm flexed
    • Entrapment at arcade of Frohse: extreme forearm pronation with wrist flexion
    • PIN: weakness of wrist extensors
  • Management:
    • Rest from activity: repeated pronation/supination
    • Myofascial release technique: for entrapment of supinator muscle
    • Adjust radial head

2. Cheiralgia paresthetica (Wartenberg’s syndrome)

  • Classic presentation: Numbness or tingling over dorsolateral aspect of wrist and hand
  • Cause:
    • Radial nerve trauma between tendons of ECRL and brachioradialis
    • Repetitive movements: pronation and supination
    • Wrist band or brace→compression
    • Direct blows to dorsolateral forearm/wrist
  • Evaluation:
    • Tinel’s sign: positive at point of compression at dorsolateral wrist
    • Pain: passive ulnar deviation and flexion of wrist
  • Management:
    • Compression: wrist brace, support, or taping and modify use
    • Repetitive Movement: rest from activity, modify movement
    • Myofascial release above area: Caution: myofascial release of area reproduces the problem

F. Fractures

1. Scaphoid

  • Classic presentation:
    • Anatomic snuff-box pain after FOOSH
    • Seen 3-6 months after trauma
  • Cause:
    • Impact injury with wrist in maximum dorsiflexion (> 90°) will fracture scaphoid
    • Radial styloid may impact midportion of scaphoid
    • Vascular supply runs distal to proximal: distal fractures heal without incident
    • Proximal pole fractures→Avascular necrosis (20% of all scaphoid fractures)
  • Evaluation:
    • Axial compression of index or middle finger
    • Percussion on the extended thumb
    • Forced dorsiflexion
    • Resisted pronation
    • Stretch patient’s pronated hand carefully into maximum ulnar deviation (Most sensitive): positive = pain in anatomic snuff box (52% predictive)
    • Radiographic Evaluation: Multiple views, at time of injury and in 2 to 3 weeks
      • Scaphoid series: PA, lateral, right and left obliques, PA with radial and ulnar deviation with fingers flexed
    • Bone scan or CT scan usually diagnostic: with high suspicion but unrevealing films
  • Management:
    • Cast immobilization
    • Follow-up films: taken 2 weeks after cast is removed
    • Further healing necessary: immobilization for 2 to 4 weeks
    • Referral: healing not progressing or displaced fracture
    • Referral: associated perilunar dislocation—capitate dislocates off lunate

2. Hook of hamate

  • Classic presentation:
    • Pain distal and radial to pisiform
    • Impact to area from fall, bat, racquet, or golf club
  • Cause:
    • Fall or blow to hypothenar eminence
    • Unstable: pull from flexor carpi ulnaris (through pisohamate ligament), opponens digiti, flexor digiti quinti, and transverse ligament
  • Evaluation:
    • Pain: 1 to 2 cm distal and radial to pisiform
    • Radiographic Evaluation: carpal tunnel view and 20° supinated view
    • Bone scan or CT scan: valuable possibly
  • Management: Fragment excision: short arm cast following for 3 to 4 months

3. Keinbock’s disease

  • Classic presentation:
    • Stiff and painful wrist
    • No history of trauma
  • Cause:
    • Avascular necrosis of lunate due to stress or compression fracture
    • Repetitive minor trauma
  • Evaluation:
    • Lunate: becomes more radiopaque than surrounding carpal bones
    • CT or MRI: more sensitive (suspicion high and radiographic confirmation is unequivocal)
  • Management:
    • Cast immobilization for about 8 weeks: allows revascularization
    • Surgery: when cast immobilization fails
      • Decompress area before collapse of lunate
      • Osteotomy of the radius to equal out short ulna possibly necessary
      • Collapse: replacement with prosthetic or autogenous material

G. Miscellaneous conditions

1. Dorsal impaction syndrome

  • Classic presentation:
    • Dorsal wrist pain
    • History: repeated forced dorsiflexion with weight bearing: gymnasts and chiropractors
  • Cause:
    • Repeated dorsiflexion: compression at dorsal wrist structures→
      • Capsulitis
      • Reactive changes:
        • hypertrophic synovitis (meniscoid of the wrist)
        • Osteocartilaginous changes: dorsal rim of scaphoid, lunate, capitates, or radius
  • Evaluation:
    • Tenderness: middorsal aspect of wrist, lunocapitate area
    • No indicators except history: unless radiographic changes are evident
  • Management:
    • Avoid offending position: forced dorsiflexion
    • Wrist brace with limiter, such as taping the front of wrist and forearm or placing padding on back of wrist (thick felt or multiple layers of moleskin)
    • Flexion exercises
    • Splinting for 2 to 3 weeks: allows healing if above procedures are ineffective
    • Chiropractor: use non-weight-bearing adjustment techniques or substitution with other soft techniques for a time

2. Ganglions

  • Classic presentation:
    • Dorsal wrist pain
    • Passive dorsiflexion makes worse
    • Small tender nodule or knot
    • Repetitive wrist activity: sports or occupational
    • Under 35 years
  • Cause:
    • Soft tissue tumors that arise from the capsule or tendon sheaths: dorsal scapholunate ligament or metacarpal heads
    • Mucinous degeneration into multiple intraligamentous cysts or larger, sometimes palpable cysts
  • Evaluation:
    • Small, occult ganglions: more symptomatic
    • MRI: may be useful
  • Management:
    • Visible ganglion: compression to rupture capsule (reappear if not surgically excised)
    • Surgery: for discomfort or effect on daily activities, occupation, or sport
    • Ganglions fluctuate in size

I. Elbow

A. Lateral epicondylitis (tennis elbow)

  1. Classic presentation: Lateral elbow pain associated with repetitive sport or occupational activity
  2. Cause:
    • Tearing of extensor carpi radialis brevis (ECRB) origin
    • May extend to extensor digitorum communis (EDC) or extensor carpi radialis longus (ECRL)
    • Angiofibroblastic hyperplasia: histologic description of tissue change
    • Repetitive movements involving:
      • Forceful wrist extension
      • Radial deviation c. Supination
    • Associated with sports and occupational activities: meat cutters, plumbers and weavers
    • Tennis: poor backhand (or serving for professionals)
  3. Evaluation:
    • Tenderness at lateral epicondyle (origin of ECRB): 5 mm anterior and distal to lateral epicondyle
    • Orthopedic Testing:
      • Cozen’s maneuver: contraction of wrist extensors with elbow flexed or extended
      • Mills’ maneuver: stretch of wrist extensors with passive wrist flexion with elbow extended
      • Middle or ring finger extension: painful→EDC
      • Wrist extension with radial deviation: ECRB or ECRL
      • Chair test: pick up light chair by chair back: elbow extension and forearm pronation—impossible with patient with lateral epicondylitis due to pain
    • Radiographic Evaluation: demonstrate calcification but rarely indicated
  4. Management:
    • Acute phase: ice and rest from inciting activity
      • Splint: wrist at 30-45° of extension on ECRB
      • Graded program: slow stretching and isometric exercise progressing to isotonic exercise of the wrist extensors with an eccentric focus, resolution, and prevention
      • Myofascial release techniques
    • Subacute phase:
      • Cross-friction massage, manipulation, mobilization
      • Tennis Modifications: Elbow brace: pneumatic or Velcro type 3.0-3.5 inches wide
        • Midsize ceramic or graphite racquet with natural gut strings
        • String tension: 3-5 pounds less (52-55 lbs)
        • Nirschl approach to proper grip size
    • Corticosteroid injections vs. Physiotherapy
      • Physiotherapy: long term benefits better (83%)
    • Ultrasound
    • Nitric oxide patch

B. Medial epicondylitis

  1. Classic presentation:
    • Medial elbow pain: repetitive activity (hammering or use of screwdriver)
    • Wrist flexion and pronation: overhead and forehand strokes
    • Golfing or throwing (golfer’s elbow)
    • Pain or weakness upon gripping
  2. Cause: Tendinopathy of origin of wrist flexors and pronator teres
  3. Evaluation:
    • Tenderness at medial epicondyle:
    • Orthopedic Testing:
      • Pain reproduced with resisted wrist flexion and pronation
      • Reverse Mills’ test: passive stretching of wrist flexors with wrist extension, keeping elbow straight
    • Elbow flexion contracture (chronic cases)→restriction of extension and/or supination
    • Neurologic Evaluation:
      • Ulnar neuropathy
      • Tinel’s sign over ulnar nerve: positive
    • Radiographic Evaluation: calcifications near medial epicondyle (20-30%)
  4. Management:
    • Acute phase:
      • Ice and rest from inciting activity
      • Splint: wrist in 10° flexion relieves tension on flexor muscle group
        • Flexor carpi radialis: 10° radial deviation
        • Pronator: blocks forearm rotation
      • Myofascial release: flexor muscle mass and pronator teres
      • Graded program: slow stretching and isometric exercise progressing to isotonic exercise of the wrist extensors with eccentric focus, resolution and prevention
    • Subacute phase:
      • Cross-friction massage, manipulation, and mobilization
      • Tennis elbow brace: redistribute forces

C. Triceps Tendinitis (posterior tennis elbow)

  1. Classic presentation:
    • Pain at tip of elbow:
      • repetitive extension activity
      • forceful elbow extension—single event
  2. Cause:
    • Strain of triceps insertion on the olecranon
    • Boxers, weight lifters, pitchers, shot-putters, tennis players
  3. Evaluation:
    • Tenderness at olecranon process
    • Pain increased with resisted elbow flexion (especially at starting position of elbow flexion)
  4. Management:
    • Myofascial release techniques for triceps
    • Cross-friction: insertion point of olecranon
    • Ice and rest from inciting activity
    • Decrease weight used in elbow extensions for patient workouts

D. Posterior impingement syndrome

  1. Classic presentation:
    • Sharp elbow pain, especially on quick extension of elbow
    • Popping or clicking with extension possible
    • Locking occasionally
  2. Cause:
    • Repetitive extension leads to posterior compression between olecranon trochlea and olecranon fossa
    • Reactive synovitis possible
    • Degeneration and production of osteophytes or loose bodies possible
  3. Evaluation:
    • Pain: also blockage to active and passive extension at end-range
    • Orthopedic Testing:
      • Valgus-extension overload test: apply valgus stress while extending elbow
      • Pain and crepitis
    • Radiographic Evaluation:
      • axial view required
      • cubital tunnel view revealing
    • CT or arthrography: necessary if radiographs are negative
      • Reveal cartilaginous bodies
  4. Management:
    • Surgery: evident loose bodies
    • Synovial hypertrophy or inching: acute pain program
      • Rest, ice
      • Extension-block brace or taping

E. Nursemaid’s elbow

  1. Classic presentation:
    • Child usually between ages 2 and 4
    • Lateral elbow pain
    • Swinging child by arms or sudden jerking of child’s arm
  2. Cause:
    • Radial head not fully formed
    • Allows damage or entrapment of annular ligament by distraction/rotation force
  3. Evaluation:
    • Exquisite lateral elbow pain
    • No obvious trauma (fall or blow)
    • Palpation: malpositioned radial head
  4. Management:
    • Reduction: elbow flexion and rotation
    • Radiographic confirmation of reduction

F. Little League elbow

  1. Classic presentation:
    • Medial or lateral elbow pain
    • Adolescent baseball pitcher usually
  2. Cause:
    • Syndrome
    • Repetitive valgus stress incurred with pitching:
      • Injury to medial elbow
        • Microtrauma to medial anterior oblique ligament
        • Fragmentation of medial epicondylar epiphysis
      • Compression injury to lateral elbow
        • Osteochondritis dessicans of capitellum
        • Radial head injury of various degrees (premature closure)
  3. Evaluation:
    • Tenderness at both medial and lateral elbow
    • Orthopedic Testing:
      • Valgus testing: laxity and/or pain requires radiographs
      • Alternating supination and pronation, active or passive: palpable or audible crepitis at head of radius (osteochondritis dissecans or radial head damage)
    • ROM:
      • Passive: flexion contracture
      • Active: popping and clicking or locking on full-range active movement
    • Radiographic Evaluation: specialized views
      • Radial head—capitellum view
      • Valgus stress view
      • Assess whether ligament or epiphyseal damage is the cause
  4. Management:
    • Orthopedic Consultation: if radiographically confirmed
    • Clinically apparent (radiographically normal): modification or elimination of inciting activity
      • Modification of pitching techniques
      • Proper mechanics
    • Acute: typical modalities used
    • Proper warm-up and stretching

G. Osteochondrosis (Panner’s disease)

  1. Classic presentation:
    • Young male
    • Unilateral (dominant arm) lateral elbow pain and stiffness
    • Clicking and locking possible
    • Sport activity several times a week usually
  2. Cause:
    • Avascular necrosis: osteochondrosis of the capitellum
      • Trauma
      • Disturbance of circulation to chondroepiphysis of capitellum c.
        • Compressed vessels supplying this area: due to unossified epiphyseal cartilage
        • No anastomosis decreasing blood supply: may be due to anomalous distribution
    • Aka: osteochondrosis deformans, osteochondritis, asceptic necrosis
  3. Evaluation:
    • History of excessive throwing (Little League pitching)
    • Repeated weight bearing (gymnastics)
    • Radiographs:
      • Diagnose Panner’s disease
      • Obliques and radial head-capitellum view
      • Fragmentation or loose body formation
    • ROM:
      • Active and passive supination and pronation with elbow extended: crepitis at radialcapitellar joint
  4. Management:
    • Best prognosis: children with open epiphysis
    • Eliminate inciting activities
    • Rest and splinting for 2 to 3 weeks
    • Gradual stretching and strengthening after rest period
    • Gradual return to activity
    • Orthopedic consultation: loose fragments or locked elbow
      • Failure of conservative trial

H. Olecranon bursitis

  1. Classic presentation: Obvious swelling just distal to the point of the elbow
  2. Cause:
    • Olecranon bursa acts as cushion Fall on elbow Repeated weight bearing or dragging of elbow on ground (wrestling) Irritation and swelling
  3. Evaluation:
    • Goose-egg swelling at elbow DDx from other swellings:
      • Tophi in gout and kidney failure DDx from infected vs. inflamed bursa:
      • infection more likely with obvious wound near bursitis Infection more warm and tender
  4. Management:
    • Protect with donut support taped to elbow Avoid inciting activity when chronic Ice or pulsed ultrasound Unsuccessful conservative treatment: aspirate and excise
      • Bursas grow back in 6-24 months
      • Infected bursae: immediately excised or aspirated

III. Hip

A. Hip fractures

  1. Classic presentation:
    1. Hip pain, unable to bear weight
      • History of fall on hip
    2. Cause:
      • Osteoporosis
      • Bone fatigue and axial muscular compressive forces: lead to falling
      • Paget’s disease, endocrinopathies, multiple myeloma, and renal osteodystrophy
      • Young: benign and malignant tumors →pathologic fractures
        • Benign tumors: Unicameral bone cyst, fibrous dysplasia
        • Malignant tumors: osteogenic sarcoma, Ewing’s sarcoma
    3. Evaluation:
      • Radiographic Evaluation:
      • Fractures: AP and lateral views
        • Intracaspsular: subcapital and transcervical
          • most common
          • result in serious complications: Osteonecrosis, nonunion, thromboembolic desease, osteomyelitis
        • Extracapsular: basicervical, trochanteric, and subtochanteric
    4. Management: Surgery

B. Stress fractures

  1. Classic presentation:
    • Young and active
    • Activities: long-distance running, gymnastics, dancing or marching
    • Insidious onset pain worse with weight bearing
    • Anterior and deep pain
  2. Cause:
    • Repetitive stress to femoral neck→microfractures
    • Cellular damage→increased remodeling
    • Osteoclastic activity exceeds Osteoblastic activity
  3. Evaluation:
    • End-range restriction and pain with flexion and internal rotation
    • Radiographs: unrevealing
    • Bone scan: highly sensitive
    • MRI: tumor is DDx
  4. Management:
    • Two Types:
      • Transverse: begins superior cortex and continues across neck
        •  Unstable
        • Serious complications
        • Percutaneous pinning
      • Compression: begins along inferior cortex
        • Progression to sclerosis possible
        • Rest and elastic support necessary for 2 weeks
        • Non-weight bearing exercises, such as bicycling and swimming after rest period
        • 4 to 6 weeks for stress fracture to heal

C. Congenital hip dislocation and hip dysplasia

  1. Classic presentation:
    • Neonate physical exam
    • Undetected: limp and diminished active abduction, if undetected
  2. Cause:
    • Acetabular deformities
    • Inversion of limbus combined with capsular tightness: dislocation and prevents stable relocation
  3. Evaluation:
    • Orthopedic Evaluation:
      • Ortolani’s click test
      • Barlow’s maneuver
    • Radiographic Evaluation: Triad
      • Underdeveloped proximal femoral epiphysis
      • Lateral displacement of femur
      • Increased inclination of acetabular roof (Putti’s triad)
    • Chronic dislocators: degenerative changes
    • MRI and diagnostic ultrasound: detect early dysplastic changes
  4. Management:
    • Dependent on age:
      • Infants to 6 months: harness (Pavlik)—holds hip in flexion and prevents adduction
      • 6 to 15 months (before walking): spica cast (for 2 to 3 months)
      • Toddlers or children not responsive to closed reduction: open reduction necessary

D. Traumatic hip dislocations

  1. Classic presentation:
    • Posterior (90%):
      • Acute injury with major force: flexed, adducted hip
      • Hip held in flexion, adduction, and internal rotation
      • Pain: severe
        • Back of leg may indicate sciatic n. damage
    • Anterior:
      • Force/blow to extended, externally rotated leg
      • Leg held in flexion, abduction, and internal rotation
  2. Cause: Acute injury
  3. Evaluation:
    • Visual observation and history
    • Radiographic Evaluation: determine extent of damage
    • (Emergency setting: Refer)
  4. Management:
    • Reduction with anesthesia
    • Rest after reduction—non-weight bearing
    • Gradual return to supported walking with crutches

E. Slipped capital epiphysis (adolescent coxa vara)

  1. Classic presentation:
    • Overweight child or rapidly growing adolescent (8-17 years old)
    • Traumatic history
    • Acute slippage possible
    • Chronic slippage: gradual hip pain with antalgia
    • Children: only knee pain sometimes
    • Most common hip condition in adolescents
  2. Cause:
    • Trauma (50%)
    • Acute slippage: Salter-Harris type I epiphyseal fracture
    • Obese individuals (Frohlich syndrome-like appearance): Hormonal influences
    • Tall, fast-growing adolescents: Hormonal influences
  3. Evaluation:
    • Physical examination: unremarkable
    • Hip passively flexed: rotates externally
    • Radiographic Evaluation: definitive diagnosis
      • Anterior view: slippage may not be visible
      • Lateral view: typical posterior/inferior slippage of femoral epiphysis
      • Bilateral views: occurrence in opposite hip (10-20%)
  4. Management:
    • Surgical pinning
    • Acute: short period of traction, first
      • Internal rotation → reduction, next
      • Pinning or screw fixation, last
    • Do not manipulate to reduce slippage: consequences can be disasterous (avascular necrosis)

F. Avascular necrosis

  1. Classic presentation:
    • Legg-Calve-Perthes disease: one form
    • Male:female: 4-5:1
    • 4-9 years (80%)
    • Mild hip pain and associated limp
    • Insidious onset
    • Knee pain only (15%)
    • Bilateral (10%)
    • Traumatic injury (17%)
    • Metabolic disease
  2. Cause:
    • Legg-Calve-Perthes disease:
      • Disruption of vascular supply to femoral head: undetermined cause
    • Secondary to:
      • Subcapital fractures
      • Posterior hip dislocations
      • Long-term steroid use
      • Hyperlipidemia
      • Alcoholism
      • Pancreatitis
      • Hemoglobinopathies
  3. Evaluation:
    • Hip abduction and internal rotation: limited
    • Trendelenburg test: positive
    • Atrophy and limb length inequality: evident over time
    • Radiographic Evaluation: definitive diagnosis
      • Small radiopaque femoral nucleus, first
      • Crescent sign, second
      • Fragmentation, third
      • Reossification with remodeling, fourth
      • Deformity of femoral head, last
  4. Management:
    • Conservative and Referral
      • No Treatment: Children < 4 years old or minor involvement (less than half of femoral head):
      • Good motion: Children 4-5 years old: no bracing or surgery (possibly)
      • Subluxation due to femoral head deformation:
        1. Petrie cast or ambulatory brace: maintain needed abduction
      • Surgical options rare: osteotomy
      • Healing takes 18 months

G. Subtrochanteric bursitis

  1. Classic presentation:
    1. Bursae:
      • Several
      • Major: subgluteus medius and subgluteus maximus
      • Well-localized lateral hip pain with minor degree of limp
      • 40-60 years old
      • Pain radiating to low back, lateral thigh, and knee (less commonly)
      • Unable to sleep on affected side
  2. Cause:
    • Any condition that leads to altered hip mechanics (LBP, leg length discrepancies, arthritic conditions, surgery, neurologic conditions with paresis
    • Loss of internal rotation
    • Discomfort = activity
    • Young: repetitive activity—friction over bursa
  3. Evaluation:
    • Greater trochanter: tenderness and swelling, sometimes
    • Palpation: “jump” sign at lower part of trochanter with knee and hip flexed
    • Orthopedic Evaluation: pain increase possible
      • Patrick test
      • Ober’s test
    • Pain increase with motion possible
  4. Management:
    • Correction of abnormal biomechanics
      • Leg length discrepancies
      • Adjustment of pelvis or hip
    • Stretching of hip abductors (proprioceptive neuromuscular facilitation/PNF techniques)
    • Side posture adjusting: contraindicated for 1 to 2 weeks during acute period
    • Modify running surface and technique (runners): avoid banked surfaces and feet crossing midline

H. Iliopectineal and iliopsoas bursitis

  1. Classic presentation:
    • Severe, acute anterior hip pain with antalgic gait
    • Pain radiating down the anterior aspect of the leg
      • Pressure on femoral
    • Position of flexion and external rotation: relieve pain
  2. Cause: Hip flexor tightness coupled with repetitive activity
  3. Evaluation:
    • Tenderness at hip (1 to 2 cm below middle third of inguinal ligament)
    • Resisted hip flexion (iliopsoas): reproduces pain
  4. Management:
    • Rest
    • Stretch hip flexors
    • Myofascial release of iliopsoas performed cautiously

I. Ischial bursitis

  1. Classic presentation:
    • Benchwarmer’s bursitis: Sitting for long periods of time on hard surfaces or horseback riding
    • Referral down back of leg mimicking sciatica possible
    • Pain relief: Pressing foot down (gas or brake pedal): due to extension of knee that rotates ischial tuberosity away from sitting surface
    • Young athlete: sprinting causes excessive hamstring contraction
      • DDx from apophysitis
  2. Cause:
    • Direct blow to bursa
    • Chronic trauma
    • Prolonged irritation from hard surface sitting
    • Chronic hamstring strains
    • Prolonged standing occasionally
  3. Evaluation:
    • Lists toward affected side
    • Shortened stride length
    • Toe standing: pain possible
    • Well-localized tenderness over ischial tuberosity
    • Orthopedic Testing:
      • SLR
      • Patrick’s test
  4. Management:
    • Acute phase: padding (small inflatable pillow)
    • Avoid inciting activity: long term management

J. Snapping hip syndrome

  1. Classic presentation:
    • No pain
    • Location of snapping: offending structure
    • Traumatic: consider acetabular labrum tear
  2. Cause:
    • Tendons snap over bony prominences or bursae
    • Abduction may cause suction effect similar to joint gapping with manipulation
    • Loose body found in joint (accompanying signs of mechanical blockage of movement)
  3. Evaluation:
    • Lateral hip snapping:
      • Hip flexion with hip adduction: Iliotibial band at greater trochanter
    • Anterior hip snapping:
      • Active extension of flexed, abducted, and externally rotated hip:
        • Iliopsoas tendon
        • Iliofemoral ligaments over the anterior joint capsule
    • Posterior hip snapping in buttocks region:
      • Biceps femoris tendon snapping over ischial tuberosity
  4. Management:
    • Benign and position dependent
    • Strengthen muscle: rather than stretching if painful or irritating to patient
    • Stabilize
    • Stretching: second treatment option

K. Transient synovitis

  1. Classic presentation:
    • Child: less than 10 years old
    • Inguinal area pain with difficulty bearing weight
    • Acute or gradual onset
    • Hip held in external rotation, abduction, and flexion
    • Viral infection: history
  2. Cause:
    • Unknown
    • Portent of rheumatoid disease or ensuing Legg-Calve-Perthes disease
  3. Evaluation:
    • Internal rotation decreased with restriction of other movements
    • Tenderness
    • Radiographs: unrevealing
    • Bone scan: diagnostic: low specificity
    • Ultrasound: fluid in joint
    • DDx: septic hip (respiratory infection preceding)
    • Aspiration: necessary for diagnosis
    • Septic Arthritis: Medical Emergency
    • MRI: helps differentiate
  4. Management:
    • Idiopathic, benign form: resolution over several weeks
      • Non-weight bearing period
      • Crutch use for several weeks

L. Osteoarthritis

  1. Classic presentation:
    • Primary OA
      • Middle-aged or elderly
      • Hip, possible buttock, groin, or knee pain with insidious onset
      • Slow stiffening noted (internal rotation)
      • Hip held in external rotation
      • Low back pain (excessive extension with weight bearing) to compensate for limited hip extension
    • Secondary OA: Similar to primary, except there is trauma or crystal deposition (Gout)
  2. Cause:
    • Primary: not common
      • Progressive degeneration of femoral and acetabular articular cartilage
      • Accumulation of microtrauma
      • Considered with preexisting abnormalities of the acetabulum or femoral head
    • Secondary:
      • Calcium pyrophosphate dehydrate crystal deposition disease, acromegaly, hemochromatosis, neuroarthropathy, and other articular problems
  3. Evaluation:
    • Passive internal rotation and extension of hip: restricted
    • Abductor or adductor contracture may develop
    • Pain reproduced: axially compressing femur into acetabulum
    • Hallmark of OA:
      • Superior joint space narrowing associated with
      • subchondral cysts and osteophytes
  4. Management:
    • Reduce weight
    • Non-weight bearing exercise
    • Strengthen joint relieves constant pain
    • Stretch hip contractures with gentle PNF or deeper myofascial release techniques
    • Cane: severe pain

M. Rheumatoid arthritis

  1. Classic presentation:
    • Woman aged 25-55 years
    • Hip pain: bilateral eventually
    • Soft tissue swelling, stiffness, ROM restriction
  2. Cause: Synovial inflammatory process that creates a destructive pannus
  3. Evaluation:
    • Radiographic Evaluation:
      • Uniform, symmetric joint space diminution superiorly
      • Bilateral eventually
      • Associated findings
        • Periarticular osteoporosis
        • Subchondral cysts
        • Osseous destruction
    • Later stages:
      • Ankylosis and protrusio acetabuli (femoral head protrudes through acetabulum)
    • Laboratory Tests:
      • ESR: elevated
      • Rheumatoid factor: positive
  4. Management:
    • Comanagement often necessary
    • Acute periods: NSAIDs
    • Mild passive movements: maintain hip motion and reduce swelling
    • Do not aggressively manipulate

N. Tumors

  1. Classic presentation:
    • 50 years or older
    • Deep bone pain
    • Insidious onset
    • Pain not relieved by rest and worse at night
    • History: Diagnosis of lung, brest, kidney, prostate, or thyroid cancer
  2. Cause: Metastasis and multiple myeloma
  3. Evaluation:
    • Laboratory Tests:
      • Elevated: ESR, serum calcium, alkaline Phosphatase, prostate-specific antigen (prostate tumor)
      • Multiple Myeloma: Bence-Jones protein, ↑ ESR, monoclonal spiking on electrophoresis, M spike on immunoelectrophoresis
    • Radiographic Evaluation:
      • Lytic: breast and kidney tumors, multiple myeloma
      • Blastic: prostate tumor
  4. Management: Refer for oncologic consultation

O. Paget’s disease

  • Classic presentation:
    • Asymptomatic (90%)
    • Increase in hat size
    • Insidious onset of low and/or hip pain, if symptomatic (10%)
  • Cause:
    • Unknown
    • Viral etiology suspected
    • Sarcomatous degeneration is a complication (< 2%)
  • Evaluation:
    • Radiographic Evaluation:
      • Cross-hatched appearance of femoral head trabeculae
      • Later: Remodeling
        • ↑ opacity and deformation
        • bowing
  • Management:
    • No medical treatment
    • Asymptomatic patients not treated
    • Symptomatic: drugs, such as calcitonin (pain) or diphophonates (inhibit osteoclast activity)

IV. Cervical

A. Disc herniation

  1. Classic presentation:
    • Neck/Arm Pain
      • Onset follows neck injury or is insidious
      • Past history of neck pain (following minor injuries)
      • Hand weakness possible
      • Deep ache
      • Hand behind head relieves
  2. Cause:
    • Nerve root irritation—result of disc herniation
    • Osteophytic compression
    • Younger than 40 years (no nucleus pulposus left in older individuals)
  3. Evaluation:
    • ROM: active and passive painful restriction (often unilateral)
    • Orthopedic Testing:
      • Cervical Compression: reproduces neck and arm pain with possible radiation into medial scapular area
      • Cervical Distraction: relieves arm pain
      • Shoulder Depression: may reproduce complaint on side of deviation
      • Hand Behind the Head: relief—decreasing traction effect
    • Neurologic Testing:
      • ↓ Deep tendon reflex
      • Weakness in myotome
      • Sensory abnormality in dermatome
    • Radiographic Evaluation: Oblique views: degree of foraminal encroachment
    • MRI/CT: Severe pain or unresponsive to nonsurgical management
    • Electrodiagnostic Studies: 3-4 weeks after onset, in no specific cause is identified
  4. Management:
    • Cervical manipulation: at sites other than the disc herniation
    • Osseous Adjusting: use a trial of mild mobilization impulses at involved level
    • Caution: chiropractor can be blamed for causing the existing herniation due to irritating the nerve
    • Nonosseous techniques: short course to determine therapeutic effect
    • Cervical traction
    • Physical therapy
    • Home traction: 15 minutes 2 times/day
    • Response evident in a few days
    • Unresponsive or in too much pain: Refer

B. Myelopathy

  1. Classic presentation:
    • Bilateral clumsiness of hands
    • Difficulty walking
    • Urinary dysfunction possible
    • Shooting pains into arms possible
    • (Different presentations depending on degree of compression)
  2. Cause:
    • Numerous causes of spinal cord compression:
      • Tumor
      • Herniated disc
      • Spondolytic sources
  3. Evaluation:
    • Neurologic Evaluation, thorough
      • Pathologic reflexes
      • Upper motor neuron signs
      • ↓ Strength, proprioception, vibration
      • Cerebellar function
      • Provocative Test: Lhermitt’s—positive (spinal cord and MS)=shooting pains into arms or legs
    • Radiographic Evaluation: Lateral view: spinal canal diameter
      • (posterior Vertebral body to laminopedical junction<13mm) indicates problems
      • 10-11 mm indicates absolute stenosis
    • CT: bony stenosis
    • MRI: other causes
    • Electrodiagnostic Testing: Degree of involvement and level (SEPs and DSEPs—latency of transmission)
  4. Management:
    • Surgery: for “hard lesions” (spondylosis or ossification of posterior longitudinal ligament)
      • Decompression surgery: spondylotic myelopathy (short-term or no effects)
      • Upper motor neuron lesions (UMNL) signs: surgery is warranted
    • Conservative Treatment: physical therapy, neutral cervical traction, nonosseous adjusting techniques (with LMNL and when surgery cannot be done)
    • No Improvement: Comanagement

C. Burner/stinger

  1. Classic presentation:
    • Sudden onset of burning pain/and or numbness
    • Pain along lateral arm
    • Arm weakness
    • Follows a lateral flexion injury of the neck/head (“whiplash”)
    • Symptoms last a couple of minutes
  2. Cause:
    • Injury of the brachial plexus or nerve roots
    • Lateral flexion injury (“whiplash”)
    • Lateral flexion away from involved side with shoulder depression: plexopathy
    • Lateral flexion with compression on involved side: nerve root compression
    • Upper trunk (C5-C6) most often affected
    • Injuries usually mild with transient symptoms
  3. Evaluation:
    • ROM: Weakness of shoulder abduction, external rotation, and arm flexion (may be delayed signs— reexamine in 1 week)
    • Radiographic Evaluation: Persistent symptoms (flexion and extension views)
    • EMG: Arm weakness after 3 weeks
    • MRI: Nerve root problem is suspected
  4. Management:
    • Caution: Avoid reproduction of injury—no lateral-flexion type adjustment
    • Strengthen neck muscles
    • Wear protective gear
    • Avoid repeated episodes—which will lead to more damage and will require neurologic consultation

D. Thoracic outlet syndrome

  1. Classic presentation:
    • Diffuse arm symptoms
    • Numbness and tingling (inside of arm to ring and little fingers)
    • Aggravated by overhead activity
  2. Cause:
    • Brachial plexus and/or subclavian/axillary arteries compression
    • C7 transverse process
    • Scalene muscles: tight and often posturally induced (forward head, rounded shoulders)
    • Costoclavicular area
    • Subcoracoid area (between coracoids and pectoralis minor)
    • Cervical Rib: fibrous band connecting cervical rib to first rib
  3. Evaluation:
    • Orthopedic Testing: Many positives and false positives (especially with radial pulse reduction)
      • Adson’s test: scalenes
      • Halstead’s test: scalenes
      • Wright’s test: pectoralis minor
      • Roo’s test: reproduce arm symptoms and weakness
    • Neurologic Evaluation: To differentiate TOS from lower brachial plexus, nerve root, or peripheral entrapment problems
  4. Management:
    • Conservative: Postural correction
      • Stretch tightened muscles: pectorals and scalenes
      • Strengthen weakened muscles: middle and lower trapezius and rhomboids
    • Trigger-point therapy
    • Taping or bracing: with proprioceptive training with postural correction
    • Adjust first rib
    • Surgery: minority of patients who do not respond to conservative management

E. Facet/referred

  1. Classic presentation:
    • Mild or moderate traumatic onset of neck and arm pain
    • Sometimes insidious with no recent trauma
    • Patients draws a line of pain down the outer arm to hand
    • Arm and hand do not fit a specific dermatome
  2. Cause:
    • Irritation of the facet joints or deep cervical muscles refers pain down the arm
    • Outer arm to hand
    • Facet joints of C5-C7
  3. Evaluation:
    • Orthopedic testing:
      • Cervical compression with neck in extension and rotation on involved side: local pain
    • Neurologic Evaluation: (If normal, may indicate no nerve root impingement)
      • Deep tendon=normal
      • Muscle strength=normal, no myotome
      • Numbness=subjective, no objective sensory findings
    • Trigger Point: supraspinatus and infraspinatus
    • Radiographic Evaluation: oblique views—foraminal encroachment
    • (Mild foraminal encroachment may cause referred pain vs. nerve root impingement (if neurologic exam is normal)
  4. Management:
    • Manipulate the neck (treatment of choice)
    • Cervical traction: if manipulation is unsuccessful
    • Myofascial Contribution: stretch-and-spray techniques, trigger-point therapy, myofascial release

F. Torticollis

  1. Classic presentation:
    • Congenital: Birth trauma (breach delivery)
      • Fixed asymmetry of the head
    • Adult: painful spasms of SCM
      • Head held in rotation, sometimes slight flexion
    • Pseudotorticollis: inability to move head in any direction without pain (no trauma or obvious cause)
    • Head held neutral
  2. Cause:
    • Congenital: Birth trauma (breach delivery)
      • Damage to SCM—SCM becomes fibrous
    • Adult:
      • CNS infection, tumor, basal ganglion disease, psychiatric disease
    • Pseudotorticollis: no known cause (all movements are painful, no deviation of the head)
  3. Evaluation:
    • DDx: High fever may suggest meningitis
    • Orthopedic Testing:
      • Kernig’s or Brudzinski’s: positive=severe pain and/or flexion of lower limbs on passive flexion of neck
    • ROM: markedly increased passive ROM in supine position
      • Use ROM as guide to decide if using manipulation is appropriate
    • Palpation: SCM and anterior neck for masses
    • Neurologic Evaluation: upper and lower motor neuron dysfunction—reveal medical referrals
    • Radiographic Evaluation: not necessary
    • MRI/CT: when CNS disease is suspected
  4. Management:
    • Congenital: Physical therapy to lengthen SCM (must be consistent and may take one year)
    • Adult: Neck manipulation and physical therapy for unknown cause
    • Pseudotorticollis: Manipulation with caution to decrease global spasm
    • Failure to resolve: Refer

V. Thoracic

A. Scheuermann’s disease

  1. Classic presentation:
    • Young male or female (age 13-17 years), male predominance
    • Midback pain and fatigue
    • ↑ Kyphosis
    • Midthoracic region affected 75% of the time
    • Thoracolumbar region affected 25% of the time
    • Incidence is as high as 8% and increased among family members
  2. Cause:
    • Vertebral growth plate trauma during the adolescent period with interruption or cessation of further growth
    • Scheuermann’s Type II (“Apprentice Kyphosis”):
      • Female gymnasts
      • Heavy weight lifting
      • Acute kyphotic angulation at one or two vertebral bodies in T10-L4 region
  3. Evaluation:
    • Postural: exaggeration of lumbar and cervical lordosis with hyperkyphotic thoracic region
      • Patient lies prone and extends chest off the table
        • Persistence of kyphosis=structural cause (Scheuermann’s) in a young person
        • Kyphosis improves=functional cause (poor habitual posture)
    • Radiographic: slight anterior vertebral body wedging (> 5° per segment in three consecutive vertebrae)
      • Schmorl’s nodes (3 consecutive vertebrae)
      • ↓ Disc height (3 consecutive vertebrae)
      • Thoracic kyphosis > 45°
      • Additional findings: mild scoliosis, limbus bones (anterior marginal Schmorl’s node representing ossification in the avulsed growth plate)
      • Lordosis measured using a modified Cobb angle with lateral radiograph
      • Atypical Scheuermann’s:
        • anterior Schmorl’s node occurring at only one or two levels at the thoracolumbar region
        • anterior wedging can be as much as 40%-50%
  4. Management:
    • Greater attention to period of growth spurt in males
    • Postural exercises and hamstring stretching for uncomplicated presentations with kyphotic curves < 60°
    • Brace or tape for proprioceptive awareness
    • Stretch anterior muscles
    • Strengthening interscapular muscles
    • Spinal extension exercises
    • Attention to compensations in cervical and lumbar curves
    • Milwaukee brace for curves over 60°
    • Surgery for curves > 80°
    • Atypical Scheuermann’s:
      • Restriction from all gymnastics participation
      • Extension bracing for several months
      • Radiographs retaken in 3 to 4 months to determine healing

B. Compression fracture

  1. Classic presentation:
    • Older patients: onset thoracic pain begins with minor event (sneezing or stepping off curb)
    • Younger patients: history of fall on buttocks and/or hyperflexion injury
  2. Cause:
    • Weakness in bone
    • Secondary to osteoporosis or cancer
    • Sufficient trauma
    • Women over 40 (35%) due to early menopause
    • Corticosteroid use (30%)
    • Hyperthyroidism (8%)
    • Malignancy (< 2%)
  3. Evaluation:
    • Long-term corticosteroid use
    • > 70 years old
    • Pathologic fracture:
      • > 50 years old with past history of cancer
      • Unexplained weight loss
      • Loss of posterior vertebral body height without a history of trauma (metastatic cancer or multiple myeloma)
      • Healing of noncomplicated fractures evident in about 3 months
    • Sharp kyphotic angle at area of fracture
    • Pain with percussion and deep pressure over involved segment
    • Radiographic Evaluation:
      • Lateral view
        • Anterior step defect–↑ stress imposed by natural kyphosis, flexion, and gravity
        • Collapse of anterior margin to < half the height of the posterior margin (unstable fracture)
        • More than 20% of wedging (unstable fracture)
    • Denis Criteria (Three column concept):
      • If 2 or more columns are disrupted, the fracture is unstable
      • The 3 columns:
        • anterior column (anterior longitudinal ligament to midvertebral body)
        • middle column (midvertebral body to posterior longitudinal ligament)
        • posterior column (posterior longitudinal ligament to supraspinous ligament)
  4. Management:
    • Refer: fractures due to metastatic cancer or multiple myeloma
    • Stable osteoporotic fractures: rest and over-the-counter pain medication
      • Acute pain severe for 2 weeks
      • Persistent pain for up to 3 months
      • Persistent pain after 3 months: retake radiographs to determine degree of healing
    • Lumbar or thoracolumbar area fracture: restrictive corset to prevent patient from making sudden movements or bending forward
    • Osteoporosis: avoid flexion exercises

C. Osteoid osteoma

  1. Classic presentation:
    • Young male
    • Well-localized midback pain
    • Pain worse at night
    • Pain relieved by aspirin
  2. Cause:
    • Benign tumors affecting posterior elements of vertebrae
    • Spine (10%): lamina>pedicle>facet>spinous process
    • Femur and tibia (50%)
  3. Evaluation:
    • Acute-angle scoliosis at tumor site (lesion on the concave side)
    • Radiographic Evaluation:
      • Small bony density that surrounds a smaller round, radiolucent nidus
    • Bone scans or tomograms: confirm or identify lesion
  4. Management: Refer: surgical removal

D. Postural syndrome

  1. Classic presentation:
    • Constant aching pain in the middle and upper thoracic regions
    • Pain relieved by activity
    • Pain aggravated by working at a desk
  2. Cause:
    • Natural imbalance between the anterior muscles and posterior muscles with a “hunched”, forward-head position
    • Large, tight muscles become chronically shortened in adapting to position: pectorals
    • Weakness and constant strain of midscapular muscles (contract eccentrically)
  3. Evaluation:
    • Hyperkyphosis
    • Trigger Points: upper and middle trapezius, rhomboids, levator scapulae, and pectorals
    • Muscle Testing: lower trapezius strength is minimal with upper thoracic extension from prone position with arms held out in front of body
  4. Management:
    • Manipulation of thoracic and related regions
    • Deep massage to decrease discomfort
    • Prevent recurrence:
      • Stretch pectorals first
      • Strengthen midscapular muscles second
      • Strengthen lower trapezius
    • Brace/Tape: increase postural awareness
    • Work place: evaluate/improve ergonomic conditions
    • Breaks in work routine: stretching and mild isometrics

E. T4 syndrome

  1. Classic presentation:
    • Upper back stiffness and achiness
    • Upper extremity numbness and/or paresthesias (“stocking and glove” distribution)
    • Possible associated headaches
  2. Cause:
    • Unknown
    • Possible sympathetic dysfunction related to vertebral dysfunction in upper thoracic region (T2-T7)
    • Causes a referred or reflex phenomenon in the arms or hands
    • Occurrence during the night or upon rising
    • Women 4:1 ratio (age 30-50 years)
    • Prolonged sitting, sustained reaching and pulling activities, shoveling, and overhead cleaning are associated
  3. Evaluation:
    • Tenderness and restriction at the involved segments (T2-T7)
    • Pressure or movement challenge: may reproduce complaints
    • Neurologic Examination:
      • Differentiate nerve root, peripheral nerve, brachial plexus, central nervous system disorders
      • Normal with T4 Syndrome
  4. Management:
    • Manipulation or mobilization of involved area
    • Postural advice and exercise

VI. Lumbar

A. Disc lesion with radiculopathy

  1. Classic presentation:
    • Low back and leg pain below the knee
    • Sudden onset from bending or twisting movement
    • History of LBP that have resolved
  2. Cause:
    • Nerve root is inflamed, but not always compressed
    • Herniated disc material causes release of irritating substances or initiates autoimmune inflammatory reaction
    • Disc, nerve root compression or inflammation may be source of pain
    • Leg pain without neurologic evidence is often referred
    • Nerve root compression: neurologic signs become evident
  3. Evaluation:
    • L4-5 or L5-S1—location of 98% of all disc lesions
    • Neurologic Examination: focus on L4-5 or L5-S1
      • L5 nerve root lesion:
        • Weakness of dorsiflexion of great toe
        • Numbness on lateral side of lower leg
      • S1 nerve root lesion:
        • Absent Achilles reflex
        • Numbness on back of calf, lateral foot, bottom of foot
        • Weakness on plantar flexion of great toe or foot
    • Orthopedic tests:
      • SLR: nerve root tension sign
        • Positive: reproduction of leg pain below 45° of elevation
      • Crossed SLR (Well-leg raise WLR): positive: confirmation
      • Braggard’s Test: Dorsiflexion of ankle at 5° below the positive SLR range confirms
    • Physiologic with electrodiagnostic studies: confirmation (rarely used—see MRI below)
    • MRI: use after 4 weeks of complaint, unless severe, unremitting pain or progressive neurologic signs are present
  4. Management:
    • Cautious side-posture adjusting (slightly extended side-lying position with facets providing protection)
      • Minimize rotary component
      • Mild mobilization
    • Softer approaches:
      • No rotation such as flexion distraction
      • Blocking
      • Activator adjusting
    • Surgery rarely needed (2-4%)
    • Heat and shrink the disc in patients with discogenic pain (intradiscal electrothermal annuloplasty IEA) and (intradiscal electrothermal thermography, IDET)
      1. Further research is needed
    • Macro and microdiscectomy has a reported success rate of 80-96% (long-term outcomes are yet to be measured)

B. Facet syndrome

  1. Classic presentation:
    • Well-localized LBP with hip/buttock or leg pain above the knee
    • Sudden onset after a movement or arising from a flexed position
  2. Cause:
    • Facet and its capsule are source of pain
    • Synovial folds (meniscoids) become entrapped or pinched and cause pain
    • Synovium and capsule have nerves sensitive to substance P and small diameter nociceptors
    • Degeneration
  3. Evaluation:
    • DDx facet vs. disc/nerve root irritation:
    • Facet:
      • Absence of neurologic deficits
      • Absence of nerve root tension signs/tests
      • Pain localized with Kemp’s maneuver (extension and rotation)—with SLR, do not extend below the knee
    • Radiographic Evaluation:
      • Signs of facet imbrications using the lumbar or lumbosacral disc angle, or Hadley’s S curve (variability or normal findings in asymptomatic patients makes these questionable)
      • Disc angle > 15° is strong evidence of facet imbrication
  4. Management:
    • Spinal adjusting: ↑ gapping of Z joints
    • Responsive to adjustment:
      • Adjustment frees trapped meniscoid tab
      • Large-fiber input causes reflex changes: reduces muscle spasm and reflex-mediated pain
    • Medical approaches: radiofrequency facet denervation (promising for chronic, LBP sufferers) and facet injections.

C. Canal stenosis

  1. Classic presentation:
    • > 50 years old
    • Back and leg pain: unilateral or bilateral, diffuse
    • Onset of leg complaints from walking (claudication)
    • Relief of leg complaints after resting 15-20 minutes or by maintaining a flexed posture
  2. Cause:
    • Stenosis:
      • Central or lateral
      • Bony or soft tissue encroachment
      • Congenital or acquired
    • Varied symptoms
    • Multiple levels of stenosis (leg pain)
    • Trefoil shape of spinal canal: central and lateral stenosis
    • Pedicogenic stenosis: anatomically short pedicles
    • Acquired stenosis: bony outgrowths from facets, laminae, pedicles, degenerative spondylolisthesis, or hypertrophied and/or calcified ligamentum flavum
    • Postoperative stenosis: consequence of decompressive surgeries (laminectomies)
  3. Evaluation:
    • Older patient with multilevel findings Neurogenic or vascular claudication: bicycle or walking test—patient can bicycle or walk further when flexed (opens canal and intervertebral foramina and takes pressure off neural structures, theoretically)Improvement with flexion points to canal stenosis
    • Radiographic Evaluation:
      • Lateral lumbar film: Eisenstein or Beuler method
        • Normal canal: 15mm or greater
        • Relative stenosis: 12mm
        • Absolute stenosis: 10mm
    • CT scan: suspected bony stenosis
    • MRI: suspected soft tissue encroachment
    • Electrodiagnostic studies: suspected multiple nerve root levels affected (DSEPs more valuable than EMG)
  4. Management:
    • Treatment based on the underlying cause of stenosis
    • Patients may improve or remain stable without treatment
    • Manipulative therapy: use caution (could increase compression and worsen symptoms)
    • Surgery: decompression of area: patient has severe neurologic deficit or fails to respond to conservative care (Best outcome for patients with the worst symptoms)
    • Aggressive therapies: exercise, analgesics, epidural steroid injections

D. Spondylolisthesis

  1. Classic presentation:
    • Several types: most common are isthmic
    • Isthmic types occur in young, degenerative, and older patients
    • Asymptomatic or LBP, made worse with extension
    • Older patients: degenerative spondylolisthesis may cause signs of stenosis
  2. Cause:
    • Isthmic type:
      • Stress fracture of pars interarticularis (spondylolysis) or…
      • Elongated pars
      • 2:1 ratio boys to girls
    • L5: 90% spondylolytic spondylolisthesis
    • Spondylolysis type: symptomatic in children > 5 years old
    • Slippage more common in girls
    • Sports requiring hyperextension: gymnastics cause problems
    • Alaskan Eskimos: high incidence
  3. Evaluation:
    • One-legged balance test: increased back or leg pain
      • Balance on one leg and hyperextend at the lumbar region
    • Palpation: prominent spinous process at involved level
    • Steep sacral base angle
    • Radiographic Evaluation: (Best diagnosis) lateral film
      • Radiographic grading: Divide sacrum (for L5) or inferior vertebra (for any vertebrae superior to L5) into fourths
        • Each 1⁄4 slippage anterior to posterior of the sacrum or vertebra is considered a grade (e.g. 3⁄4 slippage anterior to posterior is considered a grade 3)
      • Oblique radiographs: assess pars interarticularis integrity
      • Stability of spondylolisthesis radiograph
        • Traction radiograph: patient hangs from a bar
        • Compression stress radiograph: 20-kg rucksack on shoulders
      • Sagittal pelvic tilt index: objective measure quantifying relationship between
        • S2, center of the hip, and L5
        • A decrease in the sagittal pelvic tilt index = slip progression and risk of conservative treatment failure
    • Single-photon emission tomography (SPECT): distinguish athletic patients requiring anti-lordotic brace vs. an “active” lesion
  4. Management:
    • Grade 1: most are asymptomatic and stable
    • Progressive slippage is rare
    • Children under 10 years: majority of slippage
    • Adults: progression rarely greater than 18% anterior displacement
    • Grade 2: symptomatic possible, but stable
    • Grades 1 and 2: Good response to manipulative management
    • Grades 3 and 4: Surgical consultation
    • SPECT: hot bone scan: patient placed in brace for several weeks
    • Follow-up scans

E. Sacroiliac sprain and subluxation

  1. Classic presentation:
    • Pain over unilateral SI joint after straightening up from a stooped position (lifting an object)
    • Pain may radiate down back of leg
    • Sprain:
      • Pain is often sharp and stabbing
      • Relieved by sitting or lying
    • Subluxation: Pain less often affected by posture
  2. Cause:
    • SI dysfunction may account for almost half of all LBP cases
    • Sudden lifting or bending may cause a sprain or subluxation: in young, pregnant, degenerative disease
  3. Evaluation:
    • Joint play: direct compression or distraction increase the pain (sometimes decrease the pain)
    • Orthopedic Tests:
      • Gaenslen’s: posterior pain = SI involvement
      • Gillet test: Motion test of SI joints determines restricted movement
    • Combination of signs to evaluate: patient presentation, history, and SI tests
    • Laboratory Testing: Seronegative arthritides:
      • AS: marked decreases in forward flexion without significant pain
      • Reactive: history of painful urination, eye pain, palms and soles irritation
      • Psoriatic: extensor or scalp skin lesions
  4. Management:
    • Acute SI sprains best managed with SI support (brace)
    • Adjusting SI joint done cautiously: avoid increased stretch to ligaments
    • Usually dramatic relief with adjustment
    • Isolated contraction of transverse abdominals: effective stabilization of SI joint with laxityand pain
      • “drawing in” of abdominal wall contraction, not a “brace” using all abdominal muscles

F. Piriformis syndrome

  1. Classic presentation: Buttock and Posterior leg pain with nontraumatic onset
  2. Cause:
    • Sciatic nerve compressed by piriformis muscle
    • Sciatic nerved coursing between two muscle bellies in 15% of population
  3. Evaluation:
    • ROM: resisted external rotation of the hip or passive medial rotation of the hip may increase pain
    • Orthopedic Tests:
      • SLR with internal rotation:
        • Distinguish between nerve root or piriformis involvement
        • Interpret carefully: nerve root irritation may also increase pain with this maneuver
    • Palpation: Piriformis—may cause referred pattern down the back of the leg
    • Predisposition to piriformis syndrome:
      • Short leg
      • Pronation
      • Pelvic rotation
  4. Management:
    • Postisometric relaxation techniques
    • Myofascial techniques
    • Acute stage: physical therapy pain modalities
    • Injection of piriformis trigger point: rare cases

G. Ankylosing spondylitis

  1. Classic presentation:
    • Young man usually
    • Chronic low back pain and stiffness
    • Occasional radiation of pain into buttocks, anterior, or posterior thighs
    • Stiffness upon rising
    • Relief of complaints with moderate or mild activity
  2. Cause:
    • Inflammatory arthritis that affects SI joints
    • Enthesopathy (inflammation at site of ligamentous insertions)
    • % of whites, 0.25% of blacks
    • Men to women 3:1 ratio, women less severe
    • Earlier onset, more progressive disease
    • Gradual stiffening
    • Loss of lumbar lordosis
    • Increase in thoracic kyphosis
    • Decrease in chest expansion: due to costotransverse joint involvement
    • Heart: arterioventricular conduction defects and aortic insufficiency in 3-5% of patients
    • Peripheral joint involvement 50% of time
    • Most affected joints: hips, shoulders, knees
  3. Evaluation:
    • Two validated outcome measures:
      • Bath Ankylosing Spondylitis Radiology Index (BASRI)
      • Bath Ankylosing Spondylitis Functional Index (BASFI)
    • Genetic factors are more important than environmental factors
    • Predictors for poor outcome:
      • Male
      • Smokers
      • Iritis
      • Hip involvement
      • Higher disease activity scores
    • Fatigue
    • Osteopenia: risk factor for compression fractures in advanced disease
    • ROM: global decrease of lumbopelvic area with chronic back pain and stiffness
      • Measure with an inclinometer or tape measure using the Schober method
    • Orthopedic and Neurologic Tests: normal
    • Chest expansion decreased with chronic movement
    • Anterior uveitis (15-20% of patients)
    • Laboratory Testing: Elevated ESR (85% of cases): nonspecific and not diagnostic
    • HLA-B27 (90% of cases): nonspecific and not diagnostic
    • Negative rheumatoid factor: nonspecific and not diagnostic
    • Radiographic Evaluation: Diagnostic
      • SI joint: “pseudowidening”, erosions, sclerosis
      • Spine: early changes include marginal sclerosis
        • Erosion of the superior/inferior margins of the vertebral bodies
        • Erosion causes a “squaring” appearance on lateral view
      • Calcification of spinal ligaments and annulus fibrosus: “trolley track” sign
      • Eventual fusion: bamboo spine appearance
      • Peripheral joints: periosteal reaction at ligament/tendon insertion points of
        • Iliac crest
        • Achilles
        • Plantar fascia
    • Radiographic changes not visible for 4-6 years after onset of symptoms (ESR and HLA-B27 can be helpful)
  4. Management:
    • Unpredictable course of remission and relapses
    • Manipulation: gentle due to inflammatory nature of disease
      • to keep spine flexible, stretching, postural, and breathing exercises
      • Early stages: allows for intersegmental movement
    • Severe progression: monitor for cardiac and pulmonary involvement
    • Avoid long term use of pain medication: gastric and renal consequences

H. Reactive arthritis

  1. Classic presentation:
    • Young male
    • LBP beginning after:
      • Urethritis (burning on urination)
      • Conjunctivitis (eye pain)
      • Skin lesions on soles or palms
  2. Cause:
    • Seronegative (negative for rheumatoid factor) arthropathy following an infection
    • Chlamydia, Campylobacter, Salmonella, and Yersinia
    • HLA-B27 marker may indicate those prone to reactive arthritis
  3. Evaluation:
    • Diagnostic Tetrad
      • Conjunctivitis: resolves in a day or two
      • Mucocutaneous lesions: tongue, plate, and penis or plantar keratogenous lesions of the foot
      • Urethritis: a first symptom and unresponsive to antibiotics
      • Arthritis: knees and ankles asymmetrically
        • SI joint most common symptomatic joint
    • Mechanical Testing: SI joint = ↑ pain
    • Laboratory Testing: ↑ ESR and HLA-B271, but negative for rheumatoid factor
    • Radiographic Evaluation: subtle at SI joint in early stages
      • Unilateral involvement:
        • Joint space narrowing
        • Erosive changes
        • Eburnation of subchondral bone
    • “Sausage” fingers or toes due to marked swelling and ankylosis
  4. Management:
    • Antibiotics are ineffective
    • Management: symptomatic
    • Manipulation: may aggravate symptoms due to inflammatory nature of disease
    • Nonarticular complaints resolve over days or weeks
    • Joint involvement: progressive and permanent (especially with recurrent infection)

I. Multiple Myeloma

  1. Classic presentation:
    • > 50 years old
    • Persistent back pain unrelieved by rest
    • Pain is worse at night
    • Associated rib pain
  2. Cause:
    • Malignant disease
    • Proliferation of plasma cells with replacement of bone marrow
    • Results in osteoporosis, hypercalcemia, anemia, renal disease, and infection (often pneumonia)
    • Suppression of normal immunoglobulins
  3. Evaluation:
    • Older patients: unexplained LBP
    • Laboratory Testing: anemia with normal erythrocyte morphology
      • ↑Rouleau formation
      • Hypercalcemia
      • ↑ Globulins
      • 24 hour urine test: Bence-Jones protein (light chain)
      • Electrophoresis: monoclonal spiking
      • Immunoelectrophoresis: elevated immunoglobulin G (IgG)
      • Definitive Diagnosis: bone marrow aspirate showing more than 20% plasma cells
    • Radiographic Evaluation: osteopenia followed by widespread lytic lesions in the:
      •  Spine
      • Ribs
      • Skull
      • Punched out or rat-bite lesions
      • MM vs. metastasis to the spine: MM does not usually affect posterior elements, such as pedicles
  4. Management:
    • Treatment: palliative
    • Chemotherapy or radiation therapy: relieve bone pain
    • Bone marrow transplant: curative for patients under 55 years
    • Survival rate: variable
      • In general, patients with IgG less than 5g/dL, no anemia, no renal disease, or no lytic lesions: survival rate 5-6 years

J. Metastatic carcinoma

  • Classic presentation:
    • > 50 years old
    • Insidious, persistent pain
    • Pain worse at night, not mechanically affected
    • Weight loss and fatigue
    • (Patient sometimes remains asymptomatic until late in disease, or becomes symptomatic after trauma because of pathologic weakness of vertebrae.)
  • Cause:
    • Accounts for only 1% of LBP.
    • Metastases from breast, prostate, lung, and kidney
    • Prostate spreads through Batson’s plexus to vertebrae
    • May involve vertebral bodies, pedicles, and neural arches
    • Replacement of fatty bone marrow with nonfatty tumor cells
    • Destruction of trabeculae with a periosteal response with lytic metastasis
    • Osteoblastic or sclerotic response with metastasis of the prostate type
  • Evaluation:
    • History of prior cancer
    • Unexplained weight loss
    • Unresponsiveness to conservative care for 1 month
    • Older patients: 50 years of age
    • Radiographic Evaluation:
      • Osteolytic process: missing or one-eyed pedicle (as seen with breast cancer)
      • Osteoblastic process: ivory vertebrae (as seen with prostate cancer)
      • Compression fracture of the vertebrae with posterior collapse
    • Laboratory Testing:
      • ↑ serum calcium levels: osteolytic processes
      • ↑ alkaline phosphatase levels: osteoblastic processes
      • PSA (prostate specific antigen) with digital rectal exam: prostate cancer suspects
    • Bone scans: degree of spinal involvement with regard to location
    • MRI: volume of involvement at any individual site
  • Management:
    • Refer: oncologic consult
    • Comanagement discussed

K. Infectious spondylitis

  1. Classic presentation:
    • Deep back pain
    • Possible fever
    • Recent respiratory or urinary tract infection (or intravenous drug use or diabetes)
    • Antalgic
    • Difficulty sleeping because of pain
  2. Cause:
    • Infection of both the disc and the vertebral body
    • Adults: more common with history of
      • Urinary tract infection
      • Intravenous drug abuse
      • Recent use of an indwelling catheter postsurgery
      • Skin infection
    • Children: discitis (usually benign) without vertebral body involvement
    • Infection is spread through:
      • Arterial system
      • Batson’s venous plexus
      • Direct inoculation through surgery
    • Two types:
      • Pyogenic: Staphylococcus, Streptococcus, and gram-negative organisms
      • Nonpyogenic: tuberculosis (usually), Brucella, or fungi
  3. Evaluation:
    • Adults: deep pain made worse with pressure or percussion of the spinous process
    • Fever: often present
    • Radiographic Evaluation: 3-4 weeks to become evident
    • Pyogenic causes: more than one vertebra, disc often unaffected
    • Bone lysis: followed by sclerosis in vertebral bodies
    • Posterior elements rarely affected, but sometimes they are
    • L1: nonpyogenic spondylitis
    • Laboratory Testing: ↑ ESR, leukocyte response
  4. Management: Refer: orthopedic consultation to determine course of care

L. Abdominal aneurysm

  1. Classic presentation:
    • Asymptomatic until rupture, usually
    • Mild to severe middle abdominal or low back pain, if symptomatic
    • Leg pain with exertion (claudication)
  2. Cause:
    • Atherosclerotic aneurysms (weakening with dilation) occur below the renal arteries (95% of the time)
    • Incidence is 2-4% with male dominance
  3. Evaluation:
    • Asymptomatic Patients: pulsatile mid or upper abdominal mass
    • Palpation: most sensitive for size > 3.0cm
    • Auscultation: bruit possible
    • Peripheral pulses: prominent (due to arteriomegaly)
    • Radiographic Evaluation: lateral lumbar:
      • Enlarged calcific margin of aorta
      • Between L2 an L4
      • Diameter exceeding 3.8cm is considered an aneurysm
      • Erosion of anterior vertebral bodies behind aneurysm
  4. Management:
    • Referral for ultrasonography: demonstrate size and extent of involvement
    • 4-6cm diameter: surgical consultation
    • Rupture: if not excised and grafted
    • Patients 65-80 years: if less than 6cm, surgery not necessary, unless aneurysm expands > 1 cm
    • Searing/tearing pain: acute rupture needs immediate emergency management
    • Rupture: 10-20% survival rate

Source of these notes is attributed to Dr. Cara Borggren, DC, BS.