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)

Classic presentation: Lateral elbow pain associated with repetitive sport or occupational activity
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)
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
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

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
Cause: Tendinopathy of origin of wrist flexors and pronator teres
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%)
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)

Classic presentation:
- Pain at tip of elbow:
  - repetitive extension activity
  - forceful elbow extension—single event
Cause:
- Strain of triceps insertion on the olecranon
- Boxers, weight lifters, pitchers, shot-putters, tennis players
Evaluation:
- Tenderness at olecranon process
- Pain increased with resisted elbow flexion (especially at starting position of elbow flexion)
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

Classic presentation:
- Sharp elbow pain, especially on quick extension of elbow
- Popping or clicking with extension possible
- Locking occasionally
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
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
Management:
- Surgery: evident loose bodies
- Synovial hypertrophy or inching: acute pain program
  - Rest, ice
  - Extension-block brace or taping

E. Nursemaid’s elbow

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

F. Little League elbow

Classic presentation:
- Medial or lateral elbow pain
- Adolescent baseball pitcher usually
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)
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
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)

Classic presentation:
- Young male
- Unilateral (dominant arm) lateral elbow pain and stiffness
- Clicking and locking possible
- Sport activity several times a week usually
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
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
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

Classic presentation: Obvious swelling just distal to the point of the elbow
Cause:
- Olecranon bursa acts as cushion Fall on elbow Repeated weight bearing or dragging of elbow on ground (wrestling) Irritation and swelling
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
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

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

Classic presentation:
- Young and active
- Activities: long-distance running, gymnastics, dancing or marching
- Insidious onset pain worse with weight bearing
- Anterior and deep pain
Cause:
- Repetitive stress to femoral neck→microfractures
- Cellular damage→increased remodeling
- Osteoclastic activity exceeds Osteoblastic activity
Evaluation:
- End-range restriction and pain with flexion and internal rotation
- Radiographs: unrevealing
- Bone scan: highly sensitive
- MRI: tumor is DDx
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

Classic presentation:
- Neonate physical exam
- Undetected: limp and diminished active abduction, if undetected
Cause:
- Acetabular deformities
- Inversion of limbus combined with capsular tightness: dislocation and prevents stable relocation
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
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

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
Cause: Acute injury
Evaluation:
- Visual observation and history
- Radiographic Evaluation: determine extent of damage
- (Emergency setting: Refer)
Management:
- Reduction with anesthesia
- Rest after reduction—non-weight bearing
- Gradual return to supported walking with crutches

E. Slipped capital epiphysis (adolescent coxa vara)

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
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
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%)
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

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
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
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
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

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
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
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
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

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
Cause: Hip flexor tightness coupled with repetitive activity
Evaluation:
- Tenderness at hip (1 to 2 cm below middle third of inguinal ligament)
- Resisted hip flexion (iliopsoas): reproduces pain
Management:
- Rest
- Stretch hip flexors
- Myofascial release of iliopsoas performed cautiously

I. Ischial bursitis

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
Cause:
- Direct blow to bursa
- Chronic trauma
- Prolonged irritation from hard surface sitting
- Chronic hamstring strains
- Prolonged standing occasionally
Evaluation:
- Lists toward affected side
- Shortened stride length
- Toe standing: pain possible
- Well-localized tenderness over ischial tuberosity
- Orthopedic Testing:
  - SLR
  - Patrick’s test
Management:
- Acute phase: padding (small inflatable pillow)
- Avoid inciting activity: long term management

J. Snapping hip syndrome

Classic presentation:
- No pain
- Location of snapping: offending structure
- Traumatic: consider acetabular labrum tear
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)
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
Management:
- Benign and position dependent
- Strengthen muscle: rather than stretching if painful or irritating to patient
- Stabilize
- Stretching: second treatment option

K. Transient synovitis

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
Cause:
- Unknown
- Portent of rheumatoid disease or ensuing Legg-Calve-Perthes disease
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
Management:
- Idiopathic, benign form: resolution over several weeks
  - Non-weight bearing period
  - Crutch use for several weeks

L. Osteoarthritis

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)
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
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
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

Classic presentation:
- Woman aged 25-55 years
- Hip pain: bilateral eventually
- Soft tissue swelling, stiffness, ROM restriction
Cause: Synovial inflammatory process that creates a destructive pannus
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
Management:
- Comanagement often necessary
- Acute periods: NSAIDs
- Mild passive movements: maintain hip motion and reduce swelling
- Do not aggressively manipulate

N. Tumors

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
Cause: Metastasis and multiple myeloma
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
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

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
Cause:
- Nerve root irritation—result of disc herniation
- Osteophytic compression
- Younger than 40 years (no nucleus pulposus left in older individuals)
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
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

Classic presentation:
- Bilateral clumsiness of hands
- Difficulty walking
- Urinary dysfunction possible
- Shooting pains into arms possible
- (Different presentations depending on degree of compression)
Cause:
- Numerous causes of spinal cord compression:
  - Tumor
  - Herniated disc
  - Spondolytic sources
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)
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

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
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
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
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

Classic presentation:
- Diffuse arm symptoms
- Numbness and tingling (inside of arm to ring and little fingers)
- Aggravated by overhead activity
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
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
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

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
Cause:
- Irritation of the facet joints or deep cervical muscles refers pain down the arm
- Outer arm to hand
- Facet joints of C5-C7
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)
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

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
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)
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
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

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
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
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%
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

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
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%)
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)
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

Classic presentation:
- Young male
- Well-localized midback pain
- Pain worse at night
- Pain relieved by aspirin
Cause:
- Benign tumors affecting posterior elements of vertebrae
- Spine (10%): lamina>pedicle>facet>spinous process
- Femur and tibia (50%)
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
Management: Refer: surgical removal

D. Postural syndrome

Classic presentation:
- Constant aching pain in the middle and upper thoracic regions
- Pain relieved by activity
- Pain aggravated by working at a desk
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)
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
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

Classic presentation:
- Upper back stiffness and achiness
- Upper extremity numbness and/or paresthesias (“stocking and glove” distribution)
- Possible associated headaches
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
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
Management:
- Manipulation or mobilization of involved area
- Postural advice and exercise

VI. Lumbar

A. Disc lesion with radiculopathy

Classic presentation:
- Low back and leg pain below the knee
- Sudden onset from bending or twisting movement
- History of LBP that have resolved
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
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
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

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
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
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
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

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
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)
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)
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

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
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
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
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

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
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
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
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

Classic presentation: Buttock and Posterior leg pain with nontraumatic onset
Cause:
- Sciatic nerve compressed by piriformis muscle
- Sciatic nerved coursing between two muscle bellies in 15% of population
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
Management:
- Postisometric relaxation techniques
- Myofascial techniques
- Acute stage: physical therapy pain modalities
- Injection of piriformis trigger point: rare cases

G. Ankylosing spondylitis

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
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
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)
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

Classic presentation:
- Young male
- LBP beginning after:
  - Urethritis (burning on urination)
  - Conjunctivitis (eye pain)
  - Skin lesions on soles or palms
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
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
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

Classic presentation:
- > 50 years old
- Persistent back pain unrelieved by rest
- Pain is worse at night
- Associated rib pain
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
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
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

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
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
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
Management: Refer: orthopedic consultation to determine course of care

L. Abdominal aneurysm

Classic presentation:
- Asymptomatic until rupture, usually
- Mild to severe middle abdominal or low back pain, if symptomatic
- Leg pain with exertion (claudication)
Cause:
- Atherosclerotic aneurysms (weakening with dilation) occur below the renal arteries (95% of the time)
- Incidence is 2-4% with male dominance
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
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.

Share this:

Like this: