Medical Specialty Knowledge - Orthopedics

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Medical Specialty Knowledge - Orthopedics Reference Guide Version 1.0

September 2020

Medical Specialty Knowledge - Orthopedics Reference Guide

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Table of Contents

Orthopedics Anatomy ................................................................................................. 5 Shoulder .............................................................................................................................................................. 5

Elbow ................................................................................................................................................................... 7

Wrist and Hand ................................................................................................................................................... 8

Spine .................................................................................................................................................................... 9

Hip ...................................................................................................................................................................... 12

Knee ................................................................................................................................................................... 13

Foot and Ankle .................................................................................................................................................. 15

Actions of Muscles and Body Movement ....................................................................................................... 19

Orthopedics Overview ............................................................................................. 20 Orthopedics Personas ...................................................................................................................................... 20

Orthopedics Terminology ................................................................................................................................ 21

Common Acronyms .......................................................................................................................................... 24

Orthopedic Exam Details .......................................................................................... 25 Physical Examination Tests - Alphabetical List ............................................................................................. 25

Physical Examination Tests - Details on Most Common Tests .................................................................... 28

Normal Range of Motion Values ...................................................................................................................... 31

Commonly Misunderstood Terms & Layman's Terms .................................................................................. 35

Studies ........................................................................................................................ 38 Laboratory Tests ............................................................................................................................................... 38

Diagnostic Studies............................................................................................................................................ 39

Radiology Projections ...................................................................................................................................... 40

Medical Conditions - Shoulder ................................................................................. 42 SLAP Tear/Injury ............................................................................................................................................... 42

Rotator Cuff Injuries ......................................................................................................................................... 43

Subacromial Bursitis ........................................................................................................................................ 44

Medical Conditions - Elbow ...................................................................................... 45 Medial Epicondylitis (Golfer's Elbow) ............................................................................................................. 45

Lateral Epicondylitis (Tennis Elbow) .............................................................................................................. 46

Medical Conditions - Wrist & Hand .......................................................................... 47 Distal Radius Fracture ...................................................................................................................................... 47

Carpal Tunnel Syndrome ................................................................................................................................. 48

Dupuytren Contracture ..................................................................................................................................... 49

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Stenosing Tenosynovitis (Trigger Finger) ...................................................................................................... 50

Mallet Finger ...................................................................................................................................................... 51

Medical Conditions - Spine ....................................................................................... 52 Radiculopathy ................................................................................................................................................... 52

Ankylosing Spondylitis .................................................................................................................................... 53

Spinal Stenosis ................................................................................................................................................. 54

Disc Herniation ................................................................................................................................................. 55

Spondylolisthesis ............................................................................................................................................. 56

Spina Bifida ....................................................................................................................................................... 57

Scoliosis (Adolescent Idiopathic Scoliosis) ................................................................................................... 58

Medical Conditions - Hip ........................................................................................... 59 Trochanteric Bursitis ........................................................................................................................................ 59

Avascular Necrosis........................................................................................................................................... 60

Hip Dysplasia .................................................................................................................................................... 61

Medical Conditions - Knee ........................................................................................ 62 ACL Injury .......................................................................................................................................................... 62

Medial/Lateral Meniscus Tear .......................................................................................................................... 63

Medical Conditions - Foot & Ankle ........................................................................... 64 Trimalleolar Ankle Fracture ............................................................................................................................. 64

Plantar Fasciitis ................................................................................................................................................ 65

Achilles Tendinitis & Achilles Tendon Rupture ............................................................................................. 66

Achilles Tendinitis & Achilles Tendon Rupture ............................................................................................. 67

Hallux Valgus (Bunion) ..................................................................................................................................... 68

Haglund Deformity ............................................................................................................................................ 69

Diabetic Foot Ulcer ........................................................................................................................................... 70

Talipes Equinovarus (Clubfoot) ....................................................................................................................... 71

Hammer, Mallet, and Claw Toes ...................................................................................................................... 72

Medical Conditions - General.................................................................................... 74 Osteoarthritis .................................................................................................................................................... 74

Cerebral Palsy ................................................................................................................................................... 75

Charcot-Marie-Tooth Disease (CMTD) ............................................................................................................ 77

Treatment ................................................................................................................... 78 Medications ....................................................................................................................................................... 78

Therapy - Physical, Occupational, Recreational ............................................................................................ 79

Assistive Devices ............................................................................................................................................. 80

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Nonsurgical Treatments & Clinical Procedures ............................................................................................. 81

Surgical Treatments ......................................................................................................................................... 82

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Orthopedics Anatomy

Shoulder

One of the largest and most complex joints in the human body is the glenohumeral joint (shoulder). The shoulder is a ball and socket joint that consists of the scapula (shoulder blade), humerus (upper arm bone), and clavicle (collar bone).

• humerus - long bone of the upper arm

• acromion - a bony process on the scapula

• coracoid process - a small hook-like structure on the lateral edge of the superior anterior portion of the scapula; serves to stabilize the shoulder joint with the acromion

• clavicle - (collar bone) lies between the sternum (rib cage) and scapula (shoulder blade) to connect the arm to the body

• subacromial bursa - fluid-filled sac that separates the acromion from the rotator cuff; a bursa allows for the muscles and tendons of the shoulder to slide freely during shoulder movement

• tendons - flexible but inelastic cord of strong fibrous collagen tissue attaching a muscle to a bone

• scapula - (shoulder blade) connects the humerus to the clavicle

• rotator cuff - made up of the muscles teres minor, infraspinatus, supraspinatus, and subscapularis. These muscles extend from the scapula to the humeral head. It stabilizes the glenohumeral joint.

• ligaments - a short band of tough, flexible, fibrous connective tissue that connects two bones or cartilages or holds together a joint

• labrum - a ring of fibrocartilage that runs around the cavity of the scapula in which the head of the humerus fits

• articular cartilage - allows two bone surfaces to glide against each other

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Shoulder Girdle

The shoulder girdle consists of 4 joints:

• glenohumeral joint - (main shoulder joint) made up of the head of the humerus and glenoid cavity of the scapula

• acromioclavicular joint - clavicle meets the acromion

• sternoclavicular joint - clavicle meets the sternum

• scapulothoracic joint - (considered a false joint) scapula meets the ribs at the back of the chest Shoulder Nerves

There are three main nerves that begin together at the shoulder:

• radial nerve

• ulnar nerve

• median nerve

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Elbow The elbow joint connects the humerus in the upper arm and the radius and ulna in the forearm. This synovial hinge joint allows the forearm and hand to move toward (flexion) and away (extension) from the body. The elbow also allows rotation of the forearm and wrist.

• radius - bone of the lower arm that extends from the elbow to the wrist; located on the thumb side of the arm

• lateral epicondyle - protrusion on the outside of the humerus just above the elbow

• humerus - the long bone of the upper arm; originates at the socket of the shoulder and extends to the elbow joint

• medial epicondyle - protrusion on the inside of the humerus joint just above the elbow

• ulna - the smaller bone that runs through the lower arm connecting with the radius; located on the small finger side of the arm

Elbow Ligaments

• medial ulnar collateral ligament – serves as the primary stabilizer of the elbow for range of motion.

• lateral ulnar collateral ligament – stabilizer for varus and external rotation.

• annular ligament – holds the radial head against the ulna.

• joint capsule – fluid-filled sac that surrounds and lubricates the joint.

• cartilage – covering on the ends of the bones that allows the joints to slide easily against one another and absorb shock.

• tendons – attach muscle to bone.

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Wrist and Hand The wrist connects the hand to the distal end of the radius and ulna. The wrist and hand are part of the appendicular skeleton. The wrist and hand consist of 27 bones. Bones of the hand

• metacarpal bones - there are 5 bones, referred to as 1 through 5, beginning with the thumb

• phalanges - these are the 14 bones of the fingers; there are 2 phalanges in each thumb and 3 phalanges in each finger.

Distal Radius The distal radius refers to the area of the radius located near the wrist. Many times, a fracture of the distal radius is called a “wrist fracture.” The wrist connects the hand to the distal end of the radius and ulna.

Bones of the wrist

carpal bones

• scaphoid

• lunate

• triquetrum

• pisiform

• trapezium

• trapezoid

• capitate

• hamate distal radius distal ulna proximal portion of the 5 metacarpal bones

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Spine The spine is made up of five sections:

• Cervical spine has 7 vertebrae (C1-C7)

• Thoracic spine has 12 vertebrae (T1-T12)

• Lumbar spine has 5 vertebrae (L1-L5)

• Sacrum has 5 fused vertebrae

• Coccyx has 4 fused vertebrae

Cervical Spine The cervical spine is commonly referred to as the “neck.” The cervical spine is comprised of 7 vertebrae. Each cervical vertebra has the letter “C” appended with an identifying number related to its position in the vertebral column.

• atlantoaxial joint – a pivot joint formed by the atlas (C1) and axis (C2) in the cervical spine.

• atlas (C1) – the first cervical vertebra that with the axis (C2) forms the joint connecting the skull to the spine; named for the Greek mythological Titan Atlas.

o Note: When referring to the Greek figure, the name will be capitalized. We do not capitalize ‘atlas’ when using it to refer to spine terminology.

• axis (C2) – the second cervical vertebrae; forms the atlantoaxial joint with the atlas (C1).

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Thoracic Spine The thoracic spine connects the cervical spine and lumbar spine. It is the longest section of the vertebral column.

The thoracic spine is comprised of 12 vertebrae and is often referred to as the “mid or upper back.” It is the only spinal region connected to the ribcage. Each thoracic vertebra has the letter “T”appended with an identifying number related to its position in the vertebral column. Lumbar Spine

The lumbar spine is commonly referred to as the “lower back.” It is comprised of 5 vertebrae. Each lumbar vertebra has the letter “l” appended with an identifying number related to its position in the vertebral column. The lumbar spine meets the sacrum at L5-S1. This comprises the lumbosacral joint.

Sacrum and Coccyx

The sacrum is comprised of 5 fused vertebrae and is located inferior to the lumbar spine. The coccyx is commonly referred to as the “tailbone.”

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Spinal Nerves Spine issues often radiate outwards into the head, neck, arms, or legs due to spinal nerve roots. Providers will test not only the spine, but also the neck, arms, and legs as well in order to accurately diagnose a spine complaint.

• myotome - group of muscles that a single spinal nerve innervates

• nerve root - initial segment of a nerve leaving the central nervous system

• dermatome - an area of skin that is a served by a single spinal nerve

Each spinal region is responsible for communication within a different area of the body. The diagram above displays a high level overview of which spinal nerves serve which part of the body.

Spinal Cord Injuries Injuries to various parts of the body may result from damage to the spine. This diagram summarizes the effects of nerve damage along the spinal cord.

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Hip The acetabulofemoral (hip) joint is one of the largest and strongest joints in the human body. They are marvels of flexibility. When we walk, they give us power and stability. When we jump, they can handle the impact. The hip is an articulation of the pelvis and femur on each side of the body. It connects the axial skeleton to the lower extremities. The hip is a ball-and-socket synovial joint where the ball is the femoral head and the socket is the acetabulum.

The hip is formed by three parts: ilium – largest and uppermost bone of the pelvis and accounts for the width of the pelvis ischium – the curved bone forming the base of each half of the pelvis pubis – either of a pair of bones forming the two sides of the pelvis

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Knee The knee is the largest joint in the body, and one of the most easily injured. It is made up of four main structures: bones, cartilage, ligaments, and tendons. The knee allows a person to bend and straighten their legs. This enables actions such as sitting, squatting, jumping, kneeling and running.

Three bones meet to form your knee joint:

• femur – thigh bone

• tibia – shin bone

• patella – kneecap

Here are the other main structures that comprise the knee:

• medial meniscus and lateral meniscus - two wedge-shaped pieces of meniscal cartilage act as “shock absorbers” between your femur and tibia

• ligaments - Bones are connected to other bones by ligaments. The four main ligaments in the knee hold the bones together and keep the knee stable.

• articular cartilage – the ends of the femur and tibia, and the back of the patella are covered with articular cartilage. This slippery substance helps your knee bones glide smoothly across each other as you bend or straighten your leg.

• tendons – muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of your thigh to your patella. Stretching from your patella to your shinbone is the patellar tendon.

collateral ligaments - The medial collateral ligament (MCL) is on the inside of your knee, and the lateral collateral ligament (LCL) is on the outside. They control the sideways motion of the knee and brace it against unusual movement.

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cruciate ligaments - The cruciate ligaments control the back and forth motion of the knee. They cross each other to form an “X” with the anterior cruciate ligament (ACL) in front and the posterior cruciate ligament (PCL) in back. (The ACL is pictured in the diagram to the right, and the PCL is pictured in the diagram on the previous page.)

Anatomy related to the knee

• quadriceps tendon – attaches the four quadriceps muscles to the patella.

• tibial tubercle – large oblong elevation on the proximal, anterior aspect of the tibia, just below where the anterior surfaces of the lateral and medial tibial condyles end.

• patellar tendon – works with the muscles in the front of the thigh to straighten the leg

• medial joint line – joint line on the inside of the knee.

• lateral joint line – joint line on the outside of the knee.

pes anserine – united tendons of three muscles that insert onto the anteromedial surface of the proximal end of the tibia.

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Foot and Ankle The human foot is a very complex structure with 26 bones, 33 joints, and more than 100 ligaments and muscles working together to achieve a unique combination of stability and flexibility. Problems can arise in any of these specialized structures, especially with active adults. Groups of Bones in the Foot The bones of the foot provide mechanical support for the soft tissues; helping the foot withstand the weight of the body while standing and in motion. They can be divided into three groups:

• phalanges – the bones of the toes. Each toe has three phalanges – proximal (nearest), intermediate (middle) and distal (farthest) - except the big toe, which only has two phalanges.

• metatarsals – connect the phalanges to the tarsals. There are five in number – one for each digit.

• tarsals – a set of seven irregularly shaped bones. They are situated proximally in the foot in the ankle area.

Regions of the Foot The foot can also be divided up into three regions:

1. Hindfoot – is commonly known as the heel, and contains the big heel bone called the calcaneus as well as the talus bone

2. Midfoot – the arch of the foot, made up of five tarsal bones: the three cuneiform bones, the cuboid bone, and the navicular bone.

3. Forefoot – contains all of the phalanges (two in the great toe and three in the other toes) plus the metatarsal bones.

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Bones of the Foot The foot contains 26 bones: 7 tarsal bones, 5 metatarsal bones and 14 phalanges.

• phalanges - The phalanges are the bones of the toes. The second to fifth toes all have 3 phalanges--proximal, middle, and distal. The great toe has only 2 phalanges (proximal and distal). The phalanges help a person balance, walk, and run.

• metatarsal bones - The metatarsals connect the phalanges to the tarsals. There are a total of five metatarsal bones – one for each digit.

• tarsal bones - The tarsals are a set of seven irregularly shaped bones. They are situated proximally in the foot in the ankle area.

• distal phalanges - The distal phalanges support the nail and end of the toe.

• intermediate phalanges - The intermediate phalanges of the foot lie between the proximal and distal phalanges. (The big toe does not have an intermediate phalange.) These bones are remarkably small and short.

• proximal phalanges - The proximal phalanges of the foot are found at the base of the toes, the prominent, knobby ends are often called the knuckles. The proximal phalanges are the largest bones among the three types of phalanges in the toe.

• cuneiform bones - There are 3 cuneiforms: lateral, intermediate (or middle), and medial. They are wedge shaped bones, and their shape helps form a transverse arch across the foot.

• navicular bone - The navicular bone was given its name because it is shaped like a boat. It helps connect the talus, or ankle bone, to the cuneiform bones of the foot.

• cuboid bone - The cuboid bone, as its name suggests, is cube-shaped. It connects the foot and the ankle, and it also provides stability to the foot.

• talus bone - Talus (Latin for ankle) is the most superior of the tarsal bones. It transmits the weight of the entire body to the foot.

• calcaneus - The calcaneus (heel bone) is the largest bone in the foot. It takes the weight of the body as the heel hits the ground when walking.

Muscles, Ligaments, and Tendons of the Foot and Ankle

• Muscles contract and relax to move the foot.

• Ligaments are the fibrous stands that connect bones.

• Tendons are tough fibers that connect muscles to bones.

• Retinacula (retinaculum singular) are bands of connective tissue which surround tendons and hold them in place.

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Some of the major muscles, tendons, ligaments, and retinacula of the lower leg and foot are outlined in the diagram below.

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Ankle Bones The ankle is a joint that connects the foot to the leg which allows dorsiflexion and plantar flexion of the foot. The subtalar joint sits below the ankle joint and allows inversion and eversion motion of the foot.

Bones that make up the ankle joint:

• tibia (shin bone) - the larger and stronger of the two lower leg bones. It forms the knee joint with the femur and the ankle joint with the fibula and tarsus.

• fibula (calf bone) - the thinner, lower leg bone next to the tibia

• talus - a bone that sits above the calcaneus (heel bone) The protrusions seen and felt on the ankle area are as follows:

• medial malleolus - located at the medial aspect of the ankle and part of the tibia's base

• posterior malleolus - located at the posterior aspect of the ankle and is also part of the tibia's base (not pictured in the diagram to the left since it is located at the back of the foot)

• lateral malleolus - located on the lateral side of the ankle and is the low end of the fibula.

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Actions of Muscles and Body Movement Muscles function in pairs to produce movement. When the first muscle contracts, the second one relaxes to allow

movement. When the second muscle contracts, the first one relaxes to allow movement in the opposite direction. Flexion

and extension, abduction and adduction, rotation to right and to the left, supination and pronation, and eversion and

• Flexion - Ending of a joint to decrease the angle between two bones or two body parts. Opposite of extension.

o Dorsiflexion - Movement at the ankle joint, lifting the front of the foot so that the top of the foot moves toward the anterior leg. (Elevates the foot.) Opposite of plantar flexion.

o Plantar flexion - Movement at the ankle joint, lifting the heel of the foot from the ground or pointing the toes downward. (Lowers the foot/points the toes.) Opposite of dorsiflexion.

• Extension - Straightening and extending a joint to increase the angle between two bones or two body parts. Opposite of flexion.

• Abduction - Moving a body part away from the midline. Opposite of adduction.

• Adduction - Moving a body part closer to the midline. Opposite of abduction.

• Circumduction - combination of flexion, extension, adduction, and abduction

• Rotation - Moving a body part around its axis. o Internal rotation - Rotating a joint toward the midline. o External rotation - Rotating a joint away from the midline.

• Supination - Turning the palm of the hand upward. Opposite of pronation.

• Pronation - Turning the palm of the hand down. Opposite of supination.

• Eversion - Turning a body part outward and toward the side. Opposite of inversion.

• Inversion - Turning a body part inward. Opposite of eversion.

Movement/Manipulation of Body Parts: In addition to the actions of muscles described above, other terms may be used to indicate the movement of a body part. Those include:

• Elevation - Lifting a body part. Opposite of depression.

• Depression - Lowering a body part. Opposite of elevation.

• Retraction - The bringing together of a body part. Opposite of protraction.

• Protraction - The protruding or sticking out of a body part. Opposite of retraction.

• Contraction - Shortening of the length of all the muscle fibers and of the muscle itself. Opposite of relaxation.

• Relaxation - The gradual lengthening of inactive muscle or muscle fibers. Opposite of contraction.

NOTE: Be very careful to listen for "abduction" versus "adduction." They sound very similar but mean the opposite. Providers may pronounce these terms as "A-B-duction" or "A-D-duction" to help clarify which term is meant

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Orthopedics Overview

Orthopedics Personas The chart below lists some of the different medical providers who may be involved in the care of patients being treated for musculoskeletal disorders.

Job Title

Description

orthopedist, doctor of medicine (MD) a doctor who specializes in the branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the skeleton and associated structures

osteopath, doctor of osteopathy (DO) a doctor who can diagnose and treat any patient that an orthopedist with an MD can treat, but they base their treatment on osteopathy, the study of how to prevent and treat diseases by using proper nutrition and keeping the body structures in a normal anatomical relationship

chiropractor, doctor of chiropractic (DC) a doctor who can diagnose and treat patients with injuries involving the bones, muscles, and nerves by manipulating the alignment of the vertebral column

podiatrist, doctor of podiatric medicine (DPM) a doctor who can diagnose and treat medical and surgical conditions of the foot

physiatrist physicians who specialize in physical medicine and rehabilitation (PM&R). A subspecialty of physiatry is sports medicine

massage therapist allied health professionals who use pressure and manipulation of the muscles and soft tissues to relieve stress and prevent or treat muscular injuries

physical therapist allied health professionals who develop treatment and rehabilitation plans based on a physician's order. They use strengthening exercises and assistive devices (crutches, canes, wheelchairs, etc.) to improve a patient's balance and mobility and to reduce pain

occupational therapist allied health professionals who work with people who have had illnesses, injuries, and disabilities that prevent them from participating in their normal daily activities.

recreational therapist allied health professionals who help patients reduce depression, stress, and anxiety; recover basic physical and mental abilities; build confidence; and socialize effectively. They use interventions, such as arts and crafts, dance, or sports, to help their patients

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Orthopedics Terminology

Term

Description

abscess collection of liquified tissue (pus) within the skin layer

adhesion a band of contracted scar tissue that binds two parts of tissue or organs together

ambulation Walking

apophysitis irritation and inflammation of a growth plate in the bone

articulation a joint where two bones come together and join or articulate

ataxia incoordination of the muscles during movement, particularly gait

avulsion muscle tears away from the tendon, or the tendon tears away from the bone

blister a fluid-filled skin lesion caused by friction or rubbing of skin

bursa fluid-filled sac that decreases friction where a tendon rubs against a bone near a synovial joint; it contains synovial fluid

bursitis inflammation of the bursal sac because of repetitive muscular activity or pressure on the bone underneath the bursa

callus, calluses diffuse thickening of the outer layer of skin usually found on the bottom of the foot, caused by sheering pressures

capsulitis inflammation of the soft tissue surrounding a joint

cellulitis a bacterial infection involving the skin, which can be red, hot, and swollen

claudication lameness; limping

contracture fibrosis of connective tissue in skin, fascia, muscle or joint capsule that prevents normal mobility of the related tissue or joint

contusion bruise; a blunt trauma that causes bleeding in the muscle but does not break the skin

crush injury an injury caused by extreme pressure from a heavy object pressing on a body part where bruising, bleeding, broken bones, nerve damage, tissue and muscle damage, or circulation damage can occur

cyst soft tissue mass

dermatitis inflammation of the skin associated with a rash that can be itchy, red, and swollen

digit a finger or toe

dislocation describes a misaligned joint between two or more bones that is usually caused by trauma or arthritis

edema swelling

exacerbation increase in severity of a disease or of any of its symptoms

extremity an arm or a leg

fascia thin connective tissue sheet around each muscle or groups of muscles; it merges into and becomes part of the tendon

fracture broken bone

fossa a shallow depression in a bone

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Term

Description

gait abnormality a deviation from normal walking

ganglion semisolid or fluid-containing cyst that develops on a tendon, often on the wrist, hand, or foot

gangrene death of body tissue due to loss of blood supply

hemarthrosis effusion of blood into a joint cavity

hematoma a collection of clotted blood beneath the skin or nails (blood blister)

hyperkeratosis hard, callused dead tissue built up by the body in areas of pressure or friction

intermittent claudication a clinical description of muscle pain and fatigue which occurs after walking for short periods of time; the symptoms require a short period of rest and are due to peripheral arterial disease that causes arterial insufficiency

joint area where two bones come together

laceration a deep cut or tear in skin or flesh

lesion an area of abnormal tissue change; used as a description of skin problems such as warts, corns, or calluses

ligament fibrous bands that hold two bone ends together in a synovial joint

myalgia pain in one or more muscles due to injury or muscle disease

myositis inflammation of a muscle with localized swelling and tenderness

necrosis the death of body tissue; bone destruction

neuritis an inflammation of a peripheral nerve or nerves, usually causing pain and numbness

orthotics a support, brace, splint or other device used to support, align, prevent, or correct the function of movable parts of the body

• when used with regard to the foot, orthotics often refers to custom insoles used for the correction of the biomechanical problems that cause foot problems

pelvis the hip bones as well as the sacrum and coccyx of the spinal column

peroneal adjective meaning the fibula. It applies to the fibula bone as well as muscles and nerves in that area

phalanges (singular is phalanx) bones of the hands and feet

phantom limb illusion, following amputation of a limb, that the limb still exists. The sensation that pain in the removed part is known as phantom limb pain.

polymyalgia pain in several muscle groups

pressure ulcer skin breakdown caused by continuous pressure on a weight-bearing body part

prosthesis replacement of a missing part by an artificial substitute, such as an artificial extremity

reduction repositioning the bones to their proper alignment

rupture a break or tear in an organ (such as the spleen) or soft tissue (such as the Achilles tendon)

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Term Description

soft tissue mass tumors (benign or malignant) that emerge within the body that do not involve bone

spasm, muscle spasm painful but temporary condition with a sudden, severe, involuntary and prolonged contraction of a muscle (muscle cramp)

sprain overstretching or tearing of the ligament that connects bone to bone

sternum vertical bone of the anterior thorax to which the clavicle and ribs are attached. Also known as the breast bone.

strain, muscle strain overstretching of a muscle, often due to physical overexertion (also known as pulled muscle)

subluxation a partial dislocation resulting in the misalignment of a joint

tendon cordlike white band of nonelastic fibrous connective tissue that attaches a muscle to a bone

tendinitis inflammation of any tendon from injury or overuse

tenosynovitis inflammation of a tendon and the sheath around the tendon

thorax bony cage of the chest that contains the thoracic cavity with the heart, lungs, and other structures; also known as the rib cage

Be careful with these sound-alike terms

• metatars/o (bones of the foot) versus metacarp/o (bones of the hand)

• ankyl/o (stiff) does not mean ankle - tars/o means ankle

• paresis (incomplete paralysis) versus paralysis

• Note spelling of combining form for femur is femor/o

• Remember that radi/o can mean a bone of the forearm, not just radiation

• Note that tendinitis is preferred spelling as opposed to tendonitis.

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Common Acronyms

Acronym Meaning

ACL anterior cruciate ligament

ADLs activities of daily living

AE above the elbow

AK above the knee

AKA above the knee amputation

AP anteroposterior

BE below the elbow

BK below the knee

BKA below the knee amputation

BMD bone mineral density

Ca calcium

CPT carpal tunnel (syndrome)

DIP distal interphalangeal (joint)

DJD degenerative joint disease

DP dorsalis pedis (pulse)

DTRs deep tendon reflexes

EMG electromyography

Fx fracture

LLE left lower extremity

LUE left upper extremity

NHP herniated nucleus pulposus (herniated disc)

IM intramuscular

MCP metacarpophalangeal (joint)

MD muscular dystrophy

MG myasthenia gravis

MTP metatarsophalangeal joint

NSAID nonsteroidal anti-inflammatory drug

OA osteoarthritis

ORIF open reduction, internal fixation

ORTH, ORTHO orthopedics

PIP proximal interphalangeal (joint)

PM&R physical medicine and rehabilitation

PT physical therapy

RA rheumatoid arthritis

RICE rest, ice, compression, and elevation

RLE right lower extremity

ROM range of motion

RSI repetitive strain injury

RUE right upper extremity

THA total hip arthroplasty

THR total hip replacement

TKA total knee arthroplasty

TKR total knee replacement

• The list above is not exhaustive and reflects only some of the common acronyms that may be encountered in this specialty.

• Please be sure to follow your account specific directions for rules on acronym use.

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Orthopedic Exam Details The list below lists some of the common medical terms that you may encounter in medical notes dealing with nephrology.

Physical Examination Tests - Alphabetical List The physical examination (or orthopedic exam or musculoskeletal exam) is a directed exam based on the patient's complaints. The different tests can help include or exclude certain conditions. They can help narrow the diagnosis and are part of the objective portion of the encounter. See the list below for an alphabetical list of physical exam tests a provider might use during an orthopedic exam. When you begin documenting notes, we encourage you to research these terms for further details. Use this list as a reference while listening to the recordings.

Letter

Name of Physical Exam Test

A

• acromioclavicular (AC) joint distraction test

• acromioclavicular (AC) shear test

• Adams forward bend test

• Adson maneuver

• alar ligament test (lateral flexion)

• alar ligament test (rotational)

• ankle clonus test

• ankle dorsiflexion

• ankle plantar flexion

• anterior drawer test

• Allen test

• Apley compression/grinding test

• apprehension test

B

• Babinski test

• backward bending test

• Barlow test

• biceps load test

• bounce home test

• brachial plexus stretch test

• Bunnel Littler test

C

• clunk test

• Cozen test

• crank test

• crossover impingement test

D

• digital test

• digital Allen

• distraction test

• drop arm test

E

• elbow flexion/extension test

• Ely test

• empty can (supraspinatus) test

• eversion talar tilt test

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September 2020


Letter


F

• FABER test

• Feagin test

• Feiss line test

• flick test

• Finkelstein test

• fracture test

• french horn test

• Froment test

G

• Gaenslen test

• Galeazzi test

• glide test

• grind test

• Gowers sign

H

• Hawkins test / Hawkins-Kennedy impingement test

• Hautant test

• heel tap or “bump” test

• Hibb test

• hip range of motion

• hip impingement sign

• Hoffmann test

• Homans sign/test

I

• interdigital neuroma test

• intermetatarsal glide test

• inversion talar tilt

J

• Jackson compression test

• Jobe relocation test

K

• Kleiger external rotation test

• Klisic sign

• knee extension

L

• Lachman test

• Lhermitte sign/test

• load and shift test

• log roll test

• long finger flexion test

• Ludington sign

M

• Maigne test

• maximum cervical compression test

• McMurray test

• Mill test

• Murphy sign

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September 2020


Letter


N

• Nachlas test

• navicular drop test

• Neer impingement test

• Neer maneuver

• Noble compression test

O

• Ober test

• one-leg standing lumbar extension test

• Ortolani click

• O’Brien test

P

• patellar grind test

• patellar tendon reflexes

• Patrick test (FABER)

• Patrick test (FABER maneuver)

• pectoralis major contracture test

• pelvic rock test

• percussion test

• Phalen test

• piano key sign

• pivot shift test

• posterior drawer test

• posterior tibial sag

R

• reverse Phalen test

• Roos test

S

• scaption raise

• shoulder abduction test

• side-to-side test

• Shuck test

• Slocum ALRI test

• speed test / speed maneuver

• Spurling test

• squeeze test

• sternoclavicular (SC) joint stress test

• straight leg raise

• sulcus sign

• supple ples planus test

• swallowing test

T

• talar tilt test

• tap/percussion test

• telescoping sign

• TFCC lift test

• TFCC load test

• Thessaly test

• Thomas test

• Thompson maneuver

• Tinel sign

• torsion/grind/compression

• transverse compression test

• Trendelenburg test

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September 2020


Physical Examination Tests - Details on Most Common Tests Anterior drawer test - This is a common test used to determine ACL integrity. This test is used in conjunction with diagnostic imaging and other examinations to determine if an ACL has been injured. Futhermore, the anterior drawer test is utilized in the medical decision making process when recommending treatment. Barlow test - This test is used in infants to identify development dysplasia of the hip.The child is positioned supine, and the hips are flexed to 90 degrees using a neutral rotation. The test is considered positive if the hip can be dislocated passively.

Dorsalis pedis anterior pulse - Many times, providers will refer to this as "dorsalis pedis pulse." The artery runs between the first and second toes, and the pulse is palpated in the mid foot. If a dorsalis pedis pulse is not present, it may be indicative of a peripheral vascular disease, hypovolemia, or cardiac dysfunction.

FABER - FABER stands for Flexion Abduction Extension Rotation and is also referred to as the Patrick test. When positive, these movements result in provoked pain which assists in diagnosing hip, lumbar, and sacroiliac pathologies.

Letter


U

• ulnar nerve compression test

V

• valgus stress test

• Valsalva manuever

• varus stress test

• vertebral artery (quadrant test)

W

• Wartenberg test

Y

• Yeoman test

• Yergason test

• Yocum test

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September 2020


FADIR - FADIS stands for Flexion Adduction Internal Rotation and is a passive motion test used to diagnose femoroacetabular impingement (also known as hip impingement). This test is normally positive when the patient feels pain during the last part of the test.

• Affected leg is raised so the knee and hip are at 90 degree angles.

• The provider adducts the entire leg across the midline of the body.

• The provider then abducts the foot and lower calf away from the body.

Galeazzi test/sign - This test is used to assess hip dislocation in order to test for developmental dysplasia of the hip. It is primarily performed on infants by flexing the knees while they are lying down until the feet touch the surface and ankles touch the buttocks. Note: The Galeazzi test is also known as the Allis sign. Gowers sign - This sign is named for the neurologist who described it in 1879, Sir William Richard Gowers. It is positive when a person uses their hands to climb up their thighs to compensate for pelvic and proximal lower extremity muscle weakness. The Gowers sign presents in conditions such as Becker muscular dystrophy, Limb-girdle (and other muscular dystrophies), proximal ascending pseudomyopathic diseases, spinal muscular atrophy, sarcolycanopathy, polymyositis, discitis, and juvenile idiopathic arthritis. Hoffman sign - Physicians use the Hoffman sign to examine the reflexes of the upper extremities. It tests for the possible existence of spinal cord compression. The test is performed by holding the middle finger and "flicking" the nail. A positive Hoffman sign is indicated by movement of the thumb and index finger. The Hoffman sign is commonly confused with the Babinski sign. Homans sign - The test is used to indicate deep vein thrombosis (DVT), also known as a blood clot. The test is positive when there is pain present in the calf upon dorsiflexion of the foot with the lower extremity extended. Lachman maneuver - A test used for anterior cruciate ligament (ACL) integrity which may result in diagnosis of possible injury to the ACL. Lhermitte sign - Lhermitte sign suggests a lesion or compression of the cervical spine (C-spine) or lower brainstem. It is an "electrical" sensation that may radiate throughout the back and into the upper and lower extremities. The sign is typically evoked with flexion of the C-spine. A positive Lhermitte sign can be indicative of multiple sclerosis or other conditions. McMurray test - This is a common test used to detect medial and/or lateral meniscus tears. The test was named after the orthopedic surgeon Thomas Porter McMurray (1877-1949). Motor strength - The motor system evaluation is used to test the strength of different body areas. This evaluation system can be divided into the following categories:

• body positioning

• involuntary movements

• muscle tone

• muscle strength

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September 2020


Neer and Hawkins test - The Neer test is an orthopedic test that is used to test for subacromial impingement. Additionally, the Hawkins-Kennedy test is also used to test for shoulder impingement. Note: The Neer and Hawkins tests are commonly performed together.

O'Brien test - This is an orthopedic test used to detect glenohumeral joint labral tears. A positive result is known when there is pain or clicking present with full internal rotation but absent when in neutral rotation. Ortolani test - This test is conducted with the hip flexed at 90 degrees while gently abducting from an adducted position while lifting the femoral trochanter anteriorly. The test is positive when there is a palpable clunk as the hip reduces into position.

Patellar apprehension - This is a common test used to determine if there is any instability of the patella (e.g. dislocation). The test is positive when there is oral apprehension or quadriceps recruitment apprehension is present on the provocation test. Posterior drawer test - The posterior drawer test is used to test the integrity of the PCL and is performed often at the same time as the anterior drawer test. Range of motion - Range of motion (ROM) is the full potential movement of a joint. A joint may lack full ROM due to an injury, illness, previous surgery, etc. Speed test - This test is used to test for superior labral tears or bicipital tendinitis. If pain is present in the biciptal tendon or groove, the test is considered positive. Spurling test - Also known as the "maximal cervical compression test and foraminal compression test," the Spurling test assesses the cervical spine, specifically when looking for cervical nerve root compression. Straight leg raise - This is also known as Lasegue sign. It helps determine if a patient with low back pain has an underlying herniated disc. The test is positive if the patient experiences radiation of pain down the leg when the straight leg is at an angle between 30 and 70 degrees. Trendelenburg sign/test - A test used to assess hip dysfunction. When the gait indicates inadequate pelvic stability, the test is considered to be positive. A positive test is usually indicative of weakness in the hip abductor muscles.

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September 2020


Normal Range of Motion Values Every joint has a maximum potential of movement or range of motion. This section will go over the normal range of motion for certain areas of the body. Note: that most body area ranges of motion typically start at 0 margin; however, clarifications will be provided if the range does not follow this rule. Shoulder Range of Motion

Movement

Terminal Point/Degree of Motion

forward flexion/elevation 180 degrees

abduction 150 degrees

external rotation (at 90 degrees of abduction) 90 degrees

external rotation (with arm at the side) 80 degrees

internal rotation (with arm at the side) reach to T4 spinal level

internal rotation (at 90 degrees of abduction) 90 degrees

Elbow Range of Motion

Movement


flexion 150 degrees

extension 0 degrees

supination 90 degrees

pronation 90 degrees

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September 2020


Wrist Range of Motion

Movement


flexion 90 degrees

extension 90 degrees

radial deviation 20 degrees

ulnar deviation 40 degrees

Finger Range of Motion

Movement


DIP flexion 80 degrees

DIP extension 0 degrees

PIP flexion 100 degrees

PIP extension 0 degrees

Thumb Range of Motion

Movement


CMC adduction contact upper extremity

CMC palmar abduction 45 degrees

CMC radial abduction 60 degrees

CMC opposition base of the small finger

IP flexion 80 degrees

IP hyperextension 15 degrees

MCP flexion 55 degrees

MCP hyperextension 10 degrees

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September 2020


Cervical Spine Range of Motion

Movement


flexion 80 degrees


lateral flexion 45 degrees

rotation 90 degrees

Lumbar Spine Range of Motion

Movement


flexion 70 degrees


lateral flexion 30 degrees

rotation 30 degrees

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September 2020


Hip Range of Motion

Movement


forward flexion / elevation 180 degrees

abduction 150 degrees

external rotation at 90 degrees of abduction 90 degrees

external rotation with arm at the side 80 degrees

internal rotation with arm at the side reach to T4 spinal level

internal rotation at 90 degrees of abduction 90 degrees

Knee Spine Range of Motion

Movement


flexion 90 degrees


Ankle Spine Range of Motion

Movement


dorsiflexion 180 degrees

plantar flexion 150 degrees

inversion 90 degrees

eversion 80 degrees

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September 2020


Commonly Misunderstood Terms & Layman's Terms

Medical Terminology This section will introduce medical terms that are commonly misunderstood and lead to misuse, incorrect presentation, or incorrect formatting. This section of the module will steer you towards the correct term usage when it is time to document. abduction – the movement of a limb or other part away from the midline of the body adduction – the movement of a limb or other part toward the midline of the body or toward another part affect – to influence effect – to result or cause

o Ex: The side effects of the medication affected the patient’s activities of daily living. arthroplasty – the surgical reconstruction or replacement of a joint arthroscopy – surgical procedure orthopedic surgeons use to visualize, diagnose, and treat problems inside a joint autograft – a graft of tissue from one point to another of the same individual’s body allograft – a tissue graft from a donor of the same species as the recipient but not genetically identical axis – imaginary line on which the body rotates access – to be able to reach, approach, enter bruise – an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels ecchymosis – noraised, flat skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels

o Ecchymosis is not a synonym for bruise or contusion callus – the bony healing tissue which forms around the ends of a broken bone or bones; a thickened and hardened part of the skin or soft tissue, especially in an area that has been subjected to friction callous – showing or having an insensitive and cruel disregard for others cervical (in spine anatomy) - relating to the neck surgical - relating to or used in surgery (treatment of injuries/disorders of the body by incision or manipulation) cite – to quote, call upon officially site – situation or located at a specific place sight – vision, ability to see coarse – rough in texture, harsh course – path over which something moves or extends crepitance, crepitation, crepitus - these terms are all synonymous. The adjectival form is crepitant (crepitants is not a word). Although crepitance is not found in dictionaries, its frequent usage has made it acceptable, although Quality Documentation Specialists should defer to facility preference, especially in a nonverbatim environment, for editing “crepitance” to “crepitates.” (AHDI 18.1.3 disc – optical discs (e.g. CD, DVD, Blu-Ray, etc); common English spelling for something circular and flat disk – refers to magnetic media (e.g. floppy disk)

o The AMA Manual of Style 10th Edition notes ‘disc’ for ophthalmologic use. It indicates the use of ‘disk’ for all other anatomical terms. Terminologia Anatomica retains the use of ‘disc’ in reference to spinal terminology. Our company does not currently have a set standard for the spelling of this term. Always defer to clinic or provider preference when documenting disc/disk. (Note: For the purposes of consistency throughout this module, the spelling of "disc" is used.)

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September 2020


elicit – evoke, to draw out illicit – illegal, forbidden fecal sac – a mucous membrane that surrounds the feces of some species of nestling birds thecal sac – contains the cerebrospinal fluid which provides nutrients and buoyancy to the spinal cord ileum - the third portion of the small intestine, between the jejunum and the cecum. ilium - the large broad bone forming the upper part of each half of the pelvis incision – surgical cut made into skin or flesh excision – surgical removal (joint) effusion – abnormal accumulation of fluid in or around a joint swelling – an abnormal enlargement of a part of the body; not synonymous with effusion localized pain – restricted to a particular area or place; keep within a definite area radiation of pain – starts at one area but moves to another area (usually along the path of a nerve)

o Localized pain does not radiate or extend to another body area as this would be contradictory to the definition of localized.

physis – the region in a long bone between the epiphysis and diaphysis where growth in length occurs ficus – a tree, shrub, or climbing plant of a large genus that includes the figs and the rubber plant osteophyte - a bony growth on the edge of a bone spurring or bone spur - colloquial term for osteophyte plica – a fold of synovial membrane most commonly in the anteromedial aspect of the knee plaque – semi-hardened accumulation of substances from fluids that bathe an area resection – the process of cutting out tissue or part of an organ recession – pathological withdrawal of tissue from its normal position spasticity – stiff, rigid muscles spasm – sudden, involuntary tightening/contraction of the muscle TLIF - stands for 'transforaminal lumbar interbody fusion' which is a procedure that fuses the anterior and posterior columns of the spine through a posterior approach T'LIFT - brand name for a tissue retraction system Commonly Misheard Terms trigger finger

• aberration sounds like abrasion

• accept sounds like except

• acidic sounds like ascitic

• axis sounds like excess

• collaborate sounds like corroborate

• complement sounds like compliment

• corneal sounds like chorial

• deflection sounds like deflexion

• effusion sounds like infusion

• en bloc sounds like in block

• FABER sounds like “favor”

• leg length sounds like “leg link”

• I&D sounds like “IND”

• varus sounds like “various”

• OA sounds like “O8”

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September 2020


Commonly Misspelled Words

• disc/disk should be spelled according to the provider or clinic preference

• Houston view should be Hughston view

• phonetic spelling “Jew-day” view should be Judet view

• phonetic spelling “suh-key-lay” should be sequelae

• phonetic spelling “hill-sacks-leshun” should be Hill-Sachs lesion Layman's Terms vs Medical Terms

Layman's Term

Medical Term

armpit axilla

baseball finger mallet finger

bend forward flexion

big toe hallux

bone spur osteophyte

bow-legged genu varum (varus alignment)

broken (bone) fracture

bruise contusion

bunion hallux valgus

cc joint calcaneocuboid joint

clubfoot talipes equinovarus

collarbone clavicle

comes and goes Intermittent

"crunching"(with joint motion) crepitus

difficulty swallowing dysphagia

drooling sialorrhea

flat foot pes planus

frozen shoulder adhesive capsulitis

gel shots viscosupplementation injections

golfer’s elbow medial epicondylitis

heel calcaneus

hunchback / round back kyphosis

joint replacement arthroplasty

kneecap patella

knock-knee genu valgum (valgus alignment)

lack of muscle coordination ataxia

narrowing stenosis

pain in the ball of the foot metatarsalgia

pinched nerve compressed nerve

pinky or pinky finger small finger

"pins and needles" or skin "crawling" sensation paresthesia

quads quadriceps

shin bone tibia

shot injection

shoulder blade scapula

slipped disc herniated / ruptured disc

tailbone coccyx

tennis elbow lateral epicondylitis

thigh bone femur

trigger finger stenosing tenosynovitis

walking ambulation

wear (of the cartilage or the joint) degenerative changes

wrist distal radius

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September 2020


Studies

Laboratory Tests Laboratory tests are an important tool to help evaluate a patient's health. Here are some of the more common labs that may be ordered, what they are for and what abnormal levels could mean:

Laboratory Tests and Panels • Blood urea nitrogen (BUN): BUN is a waste product made by the liver. It is excreted by the kidneys. High

BUN values are seen in people on high protein diets, people who exercise strenuously, and people who have problems with their kidneys. This test will be ordered if the provider is placing the patient on a medication that is processed by the kidney to ensure that the kidney is functioning properly.

• Uric acid. This is normally excreted in urine. When the body is not excreting this properly, or if the body is producing too much of it, you could end up with gout, a condition that results in joint pain. If the patient has a swollen joint, the provider may order this to rule out gout.

• Creatine phosphokinase (CPK): This is an enzyme in the body. It is found mainly in the heart, brain, and skeletal muscle. If a patient presents with lower extremity weakness, a CPK level may be ordered. If the CPK is high in the absence of cardiac history or strenuous exercise (both of which could also cause an elevation), it could indicate skeletal muscle disease.

• Rheumatoid panel: This may be ordered if a patient has swollen joints. This panel includes the rheumatoid factor (RF) test along with other autoimmune-related tests, such as an ANA (antinuclear antibody), along with other markers of inflammation, such as a CRP (C-reactive protein), ESR (erythrocyte sedimentation rate), and along with a CBC (complete blood count) to evaluate the body’s blood cells. Rheumatoid factor: Blood test is positive in patients with rheumatoid arthritis.

• Liver function tests (LFTs): When a patient is put on a medication that may affect their liver, the provider may order LFTs. This panel may include ALT, ALP, SGOT, SGPT, GGT, alkaline phosphatase, bilirubin, albumin, and total protein.

• Albumin and globulin: These two labs may be ordered if a wound is not healing and the provider suspects poor healing secondary to nutrition and overall health.

• Hemoglobin (Hgb) and hematocrit (Hct): These two labs, often referred to as H&H, may be ordered to assess the number and quality of red blood cells. If a patient has chronic inflammation, the number of red cells is usually low. Low levels also contribute to nutritional deficiencies causing anemia.

• White blood count (WBC ), C-reactive protein (CRP), and sedimentation rate: If the provider suspects an infection, these three labs can help evaluate the severity of the infection and also how well a particular antibiotic is working against it.

• Salicylate level: This measures the amount of salicylate in the blood to find out if enough is being absorbed to reduce inflammation. (Salicylate is the main ingredient in aspirin and some other NSAIDs). This is a helpful test for people who are taking large doses of these medications for a long time since high salicylate levels can be harmful.

• Muscle enzyme tests (CPK aldolase): These tests measure the amount of muscle damage. (In some rheumatic diseases damaged muscles release certain enzymes into the blood.) These tests also can show how effective medication has been in reducing inflammation that causes muscle damage.

• Antinuclear antibody tests (ANA): These detect a group of autoantibodies that are found in most people with lupus and scleroderma and in a few people with rheumatoid arthritis.

• Human leukocyte antigen (HLA) tissue typing tests: These tests detect the presence of certain "genetic markers" or traits in the blood. For example B-27 is a genetic marker that nearly always is present in people with ankylosing spondylitis.

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September 2020


Urine Tests Several different tests may be done on a urine sample to determine its contents.The tests show whether the urine contains red blood cells, protein, or a variety of other abnormal substances.

• Urinalysis (UA): Urine test to describe the characteristics of the urine and detect substances in it. Characteristics include color, turbidity, and odor. Substances looked for include protein, glucose, blood, etc.

• 24-hour urine test: This test evaluates all the urine collected over a 24-hour period. Sometimes the creatinine passed in a 24-hour urine specimen is measured to provide a clearer picture of kidney function than the creatinine blood test. Uric acid calcium and protein tests sometimes must also be done on a 24-hour sample.

Joint fluid tests Inserting a needle into a joint and aspirating or removing synovial fluid from it can provide the doctor with valuable information. (Synovial fluid is the slippery fluid that fills a joint providing smoother movement.) An examination of the fluid may reveal what is causing the inflammation such as uric acid crystals, a sign of gout, or bacteria, a sign of infection. If crystals are found, proper medication may be prescribed. If an infection is found the specific bacteria that are causing it can be identified and the most effective antibiotic can be prescribed. Joint aspiration sometimes can relieve the pain of a badly swollen joint. Usually a corticosteroid is injected through the needle (if an infection is not present) to reduce inflammation for an extended period of time.

Diagnostic Studies In addition to lab work, diagnostic tests and other procedures may be ordered by a provider in order to check for the presence of disease, guide the course of treatment, and assess the response to treatment later in the course of the disease. The diagnostic studies and procedures ordered may include any of the following:

• Diagnostic Ultrasound: A non-invasive study that uses high-frequency sound waves to produce an image that demonstrates and quantifies soft tissue pathologies.

• Doppler Study: A noninvasive test that measures and quantifies blood flow through arteries.

• CT Scan: A device that takes cross-sectional images of a part of the body, giving the physician a three-dimensional image.

• Fluoroscopy: An imaging technique that uses dynamic x-rays to obtain real-time moving images of bones and joints.

• MRI: A medical imaging procedure that uses a magnetic field and radio waves to take pictures of your body's interior. It is used to investigate or diagnose conditions that affect soft tissue.

• Arthrography: Radiologic procedure that uses a radiopaque contrast dye that is injected into a joint. An x-ray or CT scan is then taken to view the bone ends and joint capsule.

• Bone scintigraphy: Nuclear medicine procedure in a radioactive tracer is injected intravenously and taken up into the bone. A special camera detects gamma rays from the radioactive tracer. Areas of increased uptake ("hot spots") indicate increased bone metabolism due to arthritis, fracture, osteomyelitis, cancerous tumors of the bone, or areas of bony metastasis.

• X-ray: Radiologic procedure that uses x-rays to diagnose bony abnormalities of any part of the body. X-rays are the primary means for diagnosing fractures, dislocations, and bone tumors.

• Diskography: Radiological examination of the intervertebral disc structures; used in suspected cases of herniated disc.

• Myelography: Radiography of the spinal cord after injection of a contrast medium. Used to identify and study spinal distortions caused by tumors, cysts, herniated discs, or other lesions.

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Radiology Projections It is common practice to order radiology studies to aid in determining the patient's condition. The most common radiology projections are listed below. Anteroposterior (AP) - A projection view from the front to the back. Anterior means nearer to the front; posterior means closer to the back. This is obtained by having the patient positioned so the affected side is against the imaging plate.

Flexion/Extension - A projection with the body area in flexion or extension.

Grashey View (AP glenoid view) - This is obtained by having the patient stand rotated 30-45 degrees with the back of the affected side against the imaging plate.

Judet view - Two oblique radiographic projections centered on the hip in question, tilted 45° medially or laterally from a true anteroposterior direction; useful for fractures or deformities of the acetabulum.

Lateral View - A projection view from the side.

Mortise - Projection view pertinent to assess the mortise joint of the ankle.

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September 2020


Oblique - A projection that is neither frontal or lateral, typically at a 45-degree angle.

PA View (Hand) - A projection view from the posterior (back) to the anterior (front). This is achieved for the hand by placing the affected hand palm down on the imaging plate.

Posteroanterior (PA) - A projection view from the posterior (back) to the anterior (front).

Scapular-y (Lateral Scapula View) - The patient is in an anterior oblique position with the anterior aspect of the shoulder is touching the imaging plate.

Skyline (Merchant/Laurine) view - A method of obtaining an axial view of the patella (kneecap). This projection enables the physician to assess the patellofemoral joint alignment. Merchant view: the x-ray beam is in superior-inferior direction; the detector is kept distal to knee. Laurine view: the x-ray beam is from inferior to superior; the detector is kept proximal to knee.

Sunrise View - Also known as lateral scapula view. The patient is in an anterior oblique position with the anterior aspect of the shoulder touching the imaging plate. A projection view of a flexed (bent) knee. The name comes from the image appearing like a sunrise.

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September 2020


Medical Conditions - Shoulder

SLAP Tear/Injury Superior Labrum Anterior Posterior (SLAP) - SLAP is an acronym for "Superior Labrum Anterior Posterior." A SLAP tear means the labrum is torn at the top in both the front (anterior) and back (posterior) of where it attaches to the biceps tendon.

Causes: A SLAP injury can be caused by:

• injury, such as falling onto an outstretched arm, dislocating the shoulder, or as a result of a forceful movement of the arm above the level of the shoulder

• overuse - anyone who uses their shoulder to make the same motion over and over can tear their labrum, ex: a weightlifter

• wear and tear - the labrum does a lot of work, and the older the patient gets, the more common it is to have injuries due to normal muscular wear and tear

Symptoms: With a SLAP tear, pain usually occurs when the shoulder is used to do a task, especially an overhead activity. Symptoms include:

• a catching, locking, or grinding feeling

• an unstable feeling in the shoulder

• loss of strength

• low range of motion Diagnosis: During the physical examination, the provider will move the patient's arm and shoulder into different positions to narrow down the source of the pain and to rule out other causes of pain such as a pinched nerve or inflammation. X-rays may be ordered to rule out any fractures that might be the cause of pain. An MRI with contrast (dye) can show the labrum, including any tears. Treatment: Conservative measures of treatment are tried first, including the use of anti-inflammatory drugs for pain and swelling. A referral for physical therapy is often given, for exercises to build the muscles back up. If medication and exercise don't help, then surgery might be recommended. Often, SLAP tears are repaired via arthroscopic surgery.

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September 2020


Rotator Cuff Injuries

Rotator Cuff Tendinitis - Rotator cuff tendinitis is an inflammation of the group of muscles in the shoulder together with an inflammation of the lubrication mechanism called the bursa. Bursitis is a symptom of rotator cuff tendonitis. Rotator cuff injuries are the most common cause of shoulder pain and limitation of activities in sports in all age groups. Rotator cuff tendonitis is the mildest form of rotator cuff injury.

Rotator Cuff Tear - A rotator cuff tear is a rip in the group of four muscles and tendons that stabilize the shoulder joint and let a person lift and rotate their arms (the rotator cuff). There are two kinds of rotator cuff tears. A partial tear is when one of the muscles that form the rotator cuff is frayed or damaged. The other is a complete tear, which goes all the way through the tendon or pulls the tendon off the bone.

Medical Term Meaning

tendinitis inflammation of a tendon

bursitis inflammation of a bursa

Causes: Rotator cuff injuries are common and increase with age. Rotator cuff tendinitis and rotator cuff tears are often caused by or associated with repetitive overhead activities such as throwing, raking, washing cars or windows and many other types of highly repetitive motions. It may also occur as a result of an injury, either due to trauma injury or a sports injury like baseball or tennis. Symptoms: Symptoms include:

• a ‘toothache’ like pain radiating from the outer arm to several inches below the top of the shoulder

• interference with sleep

• pain aggravated by raising the arms overhead or in activities that require reaching behind the body

• a clicking sound in the shoulder when raising the arm above the head Diagnosis: A thorough history and physical exam will be performed to lead to a correct diagnosis. X-rays will often show changes on the arm bone where the rotator cuff muscles attach, but an MRI provides the definitive diagnosis. An MRI clearly shows the muscles and indicates if the muscle is inflamed, injured or torn. Treatment: Treatments include:

• rest to allow the rotator cuff to heal (Note: If the shoulder is kept still too long, the connective tissue can thicken up and become tight. This is called frozen shoulder.)

• stopping or markedly decreasing the activity that required the use of the shoulder at or above shoulder level

• applying ice to the affected area

• anti-inflammatory medication to reduce arm and shoulder pain

• physical therapy and/or an exercise program to maintain flexibility

• avoiding lifting heavy objects

• cortisone injections which can provide temporary pain relief

• surgery, especially if there is a complete tear

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September 2020


Subacromial Bursitis Subacromial Bursitis: Subacromial bursitis occurs when the subacromial bursa becomes inflamed. Bursae (plural for "bursa") are small sacs filled with fluid. They act as thin cushions between bones and moving parts of the body like muscles and tendons. When a bursa gets swollen and fills up with more fluid than it should contain, it is called bursitis. The subacromial bursa in each shoulder helps a group of muscles and tendons known as the rotator cuff to function. If it gets swollen, it is known as subacromial bursitis.


acromion the bony projection on the superior end of the scapula

subacromial below the acromion

bursa a fluid-filled sac or saclike cavity, especially one countering friction at a joint

bursitis inflammation of a bursa

Causes: Subacromial bursitis is commonly caused by overuse or injury of the shoulder. Being very active can also harm the bursa, especially with sports that involve throwing or pitching. Other factors that can help contribute to subacromial bursitis include age (it is more likely in older people), poor posture, and poor flexibility. Symptoms: Symptoms include:

• shoulder stiffness and pain

• possible swelling and redness

• shoulder possibly sore to touch, especially on the front side

• if bursitis is advanced, the shoulder may be very difficult to move at all (frozen shoulder) Diagnosis: During a physical examination, the provider will check the shoulder's range of motion and check to see if the shoulder is warm to touch or tender. An x-ray may be ordered to rule out common ailments that cause similar symptoms, such as arthritis. An MRI scan can show if the bursa is filled with fluid. If the provider suspects that an infection is causing the bursitis, fluid from the bursa can be drained and tested. Treatment: Treatments include:

• rest (limit movements that cause pain)

• over-the-counter pain relievers

• ice to reduce swelling

• steroid injection around the shoulder bursa to manage pain

• antibiotics if an infection is the cause of the bursitis

• exercises and/or physical therapy to strengthen the shoulder

• surgery is only option if the condition worsens despite conservative treatment. Surgical measures could include removal of the inflamed bursa or removal of bone to make more room for the rotator cuff tendon

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September 2020


Medical Conditions - Elbow

Medial Epicondylitis (Golfer's Elbow) Medial Epicondylitis: The elbow joint is made up of the humerus bone in the upper arm and the ulna in the lower arm. The bony bumps at the bottom of the humerus are called epicondyles. Medial epicondylitis refers to an inflammation of the tendons that join the forearm muscles on the medial (inside) aspect of the elbow. The forearm muscles and tendons become damaged from overuse. Small tears can also develop over time that can lead to swelling and pain. Medial epicondylitis is known colloquially as "golfer's elbow."


medial middle, midline

epicondylitis inflammation of tendons surrounding an epicondyle

Causes: Medial epicondylitis is caused by the excessive force used to bend the wrist toward the palm. This can happen when swinging a golf club or pitching a baseball, Other possible causes of medial epicondylitis include weak shoulder and wrist muscles, carrying a heavy suitcase, and performing forceful activities that bend the wrist, such as chopping wood with an axe or the frequent use of hand or power tools. Symptoms: Symptoms include:

• pain and tenderness on the inner side of the elbow

• stiffness in the elbow

• weakness in the hand and wrist

• numbness and tingling radiating into one or more fingers Diagnosis: Medial epicondylitis is diagnosed based on medical history and a physical examination, where the provider will manipulate the elbow in various ways to gauge the area. X-rays can help to rule out other causes of elbow pain such as a fracture or arthritis. An MRI study may be performed as well. Treatment: Treatments include:

• resting the elbow by avoiding sports and other repetitive activities


• using a brace to help reduce tendon and muscle strain

• exercise and/or physical therapy to stretch and strengthen the tendons

• surgery is seldom necessary; however, if symptoms are prolonged despite conservative measures, then surgery may be an option

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September 2020


Lateral Epicondylitis (Tennis Elbow) Lateral Epicondylitis: The elbow joint is made up of the humerus bone in the upper arm and the ulna in the lower arm. The bony bumps at the bottom of the humerus are called epicondyles. Lateral epicondylitis refers to an inflammation of the tendons that join the forearm muscles on the lateral (outside) aspect of the elbow. The forearm muscles and tendons become damaged from overuse. This leads to pain and tenderness along the lateral elbow. Later epicondylitis is known colloquially as "tennis elbow."


medial side, to one side

epicondylitis inflammation of tendons surrounding an epicondyle

Causes: Lateral epicondylitis occurs when tendons in the elbow are overloaded, usually by repetitive motions of the wrist and arm. Although it is a common injury among athletes, lateral epicondylitis can occur in people whose jobs which feature repetitive motions, such as plumbers, painters, butchers, and carpenters. Symptoms: Symptoms include:

• pain and tenderness on the outside of the elbow that may radiate to the forearm and wrist

• weakness in the hand and wrist

• difficulty performing common tasks, such as turning a doorknob or holding a coffee cup Diagnosis: Lateral epicondylitis is diagnosed based on medical history and a physical examination, where the provider will manipulate the elbow in various ways to gauge the area. X-rays and MRIs may be ordered to rule out other causes of elbow pain. Treatment: Treatments include:

• resting the elbow by avoiding sports and other repetitive activities

• over-the-counter medications to relieve pain and swelling


• exercise and/or physical therapy to stretch and strengthen the tendons

• surgery is seldom necessary; however, if symptoms are prolonged despite conservative measures, then surgery may be an option

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September 2020


Medical Conditions - Wrist & Hand

Distal Radius Fracture Distal Radius Fracture: The radius is one of two forearm bones and is located on the thumb side. The part of the radius connected to the wrist joint is called the distal radius. When the radius breaks near the wrist, it is called a distal radius fracture. In layman's terms, a distal radius fracture is a broken wrist. The distal radius is the most commonly fractured bone in the arm. Distal refers to the end of the bone that is fractured. This injury typically occurs with one falls onto their outstretched arm. They may also occur during trauma from a vehicle accident or sports injury.


distal far, farthest

radius one of two forearm bones, located on the thumb side

Causes: A distal radius fracture usually happens due to falling on an outstretched or flexed hand. It can also happen in a car accident, a bike accident, a skiing accident or another sports activity. Symptoms: Symptoms include:

• immediate pain with tenderness when touched

• bruising and swelling around the wrist

• deformity — the wrist being in an odd position Diagnosis: To confirm the diagnosis, the provider will order x-rays of the wrist. X-rays can show if the bone is broken and whether there is displacement (a gap between broken bones). They can also show how many pieces of broken bone there are and if other bones are involved. Treatment: Treatment of broken bones follows one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed. There are many treatment options for a distal radius fracture. The choice depends on many factors, such as the nature of the fracture, if there is joint involvement, the patient's age and activity level.

• Nonsurgical treatment: If the broken bone is in a good position, a plaster cast may be applied until the bone heals. If the position (alignment) of the bone is out of place, it may be necessary to realign the broken bone fragments. "Reduction" is the technical term for this process in which the doctor moves the broken pieces into place. When a bone is straightened without having to open the skin (incision), it is called a closed reduction. After the cast is removed, physical therapy is often started to help improve the motion and function of the injured wrist.

• Surgical treatment: If the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast, then surgery may be required. Surgery typically involves making an incision to directly access the broken bones to improve alignment (open reduction). Options for holding the bone in correct position while it heals include metal pins, plates and screws, a cast, an external fixator, or any combination of those options.

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September 2020


Carpal Tunnel Syndrome Carpal Tunnel Syndrome: Carpal tunnel syndrome is a condition brought on by increased pressure on the median nerve at the wrist. The carpal tunnel is a narrow passageway surrounded by bones and ligaments on the palm side of your hand. When the median nerve is compressed, the symptoms can include numbness, tingling and weakness in the hand and arm. The anatomy of the wrist, pre-existing health problems and repetitive hand motions can contribute to carpal tunnel syndrome.


carpal relating to the bones forming the human carpus (wrist)

radius one of two forearm bones, located on the thumb side

Causes: Carpal tunnel syndrome is caused by pressure on the median nerve. Anything that squeezes or irritates the median nerve in the carpal tunnel space may lead to carpal tunnel syndrome. A wrist fracture can narrow the carpal tunnel and irritate the nerve, as can the swelling and inflammation caused by rheumatoid arthritis. The anatomy of the wrist, pre-existing health problems and repetitive hand motions can contribute to carpal tunnel syndrome. Symptoms: Carpal tunnel syndrome symptoms usually start gradually and include:

• Tingling or numbness in the fingers or hand - Usually the thumb and index, middle or ring fingers are affected, but not the little finger. A sensation like an electric shock might be felt in those fingers. The sensation may travel from the wrist up the arm. These symptoms often occur while holding a steering wheel, phone or newspaper, or may wake a person up from sleep. Many people "shake out" their hands to try to relieve their symptoms. The numb feeling may become constant over time.

• Weakness - A person may experience weakness in their hand and drop objects. This may be due to the numbness in the hand or weakness of the thumb's pinching muscles, which are also controlled by the median nerve.

Diagnosis: The provider will obtain a thorough history to ascertain the pattern of symptoms and conduct a physical exam to test the feeling and strength in the fingers and hand. An x-ray may be ordered to rule out other causes of wrist pain such as arthritis or a fracture. Studies such as electromyography and a nerve conduction study are useful to identify any damage to the median nerve and to the muscles controlled by the median nerve. Treatment: Treatment depends on the severity of the carpal tunnel syndrome symptoms.

• In the early stages of carpal tunnel syndrome, mild symptoms can be controlled by taking frequent breaks to rest the hands, avoiding activities that make symptoms worse, and applying ice to reduce swelling.

• When symptoms are mild to moderate, modalities of treatment include wrist splinting and NSAID medications to relieve pain. Corticosteroid injections can help to decrease inflammation and swelling.

• If symptoms are severe and don't respond to conservative treatments, then surgery may be recommended. The goal of carpal tunnel surgery is to relieve pressure by cutting the ligament pressing on the median nerve.

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September 2020


Dupuytren Contracture Dupuytren Contracture: Dupuytren contracture is a hand deformity that usually develops over years. With this condition, the fingers curl inwards, towards the palm, and are unable to straighten and typically gets progressively worse over time. Dupuytren's contracture mainly affects the two fingers farthest from the thumb. The affected fingers can't be straightened completely, which can complicate everyday activities such as placing the hands in pockets, putting on gloves or shaking hands. This condition is named after Guillaume Dupuytren, who first described the underlying mechanism in 1833.

Causes: Doctors don't know what causes Dupuytren's contracture. There's no evidence that hand injuries or occupations that involve vibrations to the hands cause the condition. It does tend to occur most often in older men of Northern European descent. Symptoms: Dupuytren contracture typically progresses slowly over years. The condition usually begins as a thickening of the skin on the palm of the hand. In later stages of Dupuytren contracture, cords of tissue form under the skin on the palm and can extend up to the fingers. As these cords tighten, the fingers might be pulled toward the palm, sometimes severely. The two fingers farthest from the thumb are most commonly affected, though the middle finger also can be involved. Dupuytren contracture can occur in both hands, though one hand is usually affected more severely. Diagnosis: In most cases, providers can diagnose Dupuytren contracture by the look and feel of the hands. The provider will check to see if the patient can put their hand flat on a tabletop or other flat surface. Not being able to fully flatten the fingers indicates the patient has Dupuytren contracture. Other tests are rarely necessary. Treatment: Treatment depends on the severity of the condition.

• If the disease progresses slowly, causes no pain and has little impact on the ability to use the hands for everyday tasks, the patient might not need treatment. Instead, they can wait and see if Dupuytren contracture progresses.

• Needling. This technique uses a needle, inserted through the skin, to puncture and break the cord of tissue that is contracting a finger. Contractures often recur but the procedure can be repeated, requires no incision, and does not require any physical therapy afterwards.

• Enzyme injections. This involves injecting a type of enzyme into the taut cord in the palm to soften and weaken it — allowing the doctor to later manipulate the hand in an attempt to break the cord and straighten the fingers.

• Surgery. For patients with advanced disease, surgery may be performed to remove the tissue in the palm affected by the disease. Physical therapy after surgery is usually required.

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September 2020


Stenosing Tenosynovitis (Trigger Finger) Stenosing Tenosynovitis (Trigger Finger): Stenosing tenosynovitis is condition in which one of the fingers gets stuck in a bent position. The finger may bend or straighten with a snap - like a trigger being pulled and released. It occurs when inflammation narrows the space within the sheath that surrounds the tendon in the affected finger. If trigger finger is severe, the finger may become locked in a bent position.


stenosing relating to the bones forming the human carpus (wrist)

tenosynovitis one of two forearm bones, located on the thumb side

Causes: Carpal tunnel syndrome is caused by pressure on the median nerve. Anything that squeezes or irritates the median nerve in the carpal tunnel space may lead to carpal tunnel syndrome. A wrist fracture can narrow the carpal tunnel and irritate the nerve, as can the swelling and inflammation caused by rheumatoid arthritis. The anatomy of the wrist, pre-existing health problems and repetitive hand motions can contribute to carpal tunnel syndrome. Symptoms: include:

• Finger stiffness, particularly in the morning

• A popping or clicking sensation as the finger is moved

• Tenderness or a bump (nodule) in the palm at the base of the affected finger

• Finger catching or locking in a bent position, which suddenly pops straight

• Finger locked in a bent position, which is unable to be straightened Diagnosis: No elaborate testing is required. A provider can make the diagnosis based on a patients medical history and a physical exam. During the physical exam, the provider will ask the patient to open and close their hand, checking for areas of pain, smoothness of motion, and evidence of locking. The provider will also feel the palm to see if there is a lump present. Treatment: Treatment varies depending on the severity and duration of the symptoms.

• For mild cases, treatment includes NSAIDs to relieve pain, avoiding activities that require repetitive gripping or grasping, wearing a splint at night to keep the finger in an extended position, and stretching exercises to help maintain mobility in the finger.

• For severe cases or when conservative measures have failed, the following measures may be taken: o an injection of a steroid medication near or into the tendon sheath may reduce inflammation and allow

the tendon to glide freely again. o a percutaneous release, which involves inserting a needle into the tissue around the affected tendon to

help break apart the constriction o surgery to cut open the constricted section of tendon sheath

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September 2020


Mallet Finger Mallet Finger: Mallet finger is an injury to the end of the joint of the finger or thumb which causes the fingertip to droop. It prevents the patient from actively completely straightening the finger. Although it is also known as "baseball finger," this injury can happen to anyone when an unyielding object (like a ball) strikes the tip of a finger or thumb and forces it to bend further than it is intended to go. The long, ring, and small fingers of the dominant hand are most likely to be injured.

Causes: In a mallet injury, when an object hits the tip of the finger or thumb, the force of the blow tears the extensor tendon. When that tendon is separated from the muscles it connects, it causes the fingertip to droop. Symptoms include:

• Pain, tenderness, and swelling at the outermost joint immediately after the injury

• Swelling and redness soon after the injury

• The fingertip will droop noticeably and will straighten only if pushed up with the other hand. Diagnosis: After discussing the patient's medical history and symptoms, the provider will examine the affected finger or thumb. During the examination, the provider will hold the affected finger and ask the patient to straighten it on their own. This is called the mallet finger test. X-rays are often ordered to see if any fracture has occurred and to determine if the injury pulled the bones of the joint out of alignment. Treatment: Most mallet finger injuries are treated with splinting. A splint holds the fingertip straight (in extension) until it heals. Surgical repair is considered if there is a large fracture fragment or the joint is out of line (subluxed). In these cases, surgery is done to repair the fracture using pins to hold the pieces of bone together while the injury heals. It is not common to treat a mallet finger surgically if bone fragments or fractures are not present.

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September 2020


Medical Conditions - Spine

Radiculopathy Radiculopathy: Radiculopathy describes a range of symptoms produced by the pinching of a nerve root in the spinal column. The pinched nerve can occur at different areas along the spine (cervical, thoracic or lumbar). This can lead to a variety of symptoms which are uncomfortable such as pain, weakness, and numbness. Cervical radiculopathy: Cervical radiculopathy describes a compressed nerve root in the cervical spine (neck area). Because the nerve roots in this area of the spine primarily control sensations in your arms and hands, this is where the symptoms are most likely to occur.

Thoracic radiculopathy: Thoracic radiculopathy describes a compressed nerve root in the thoracic spine (upper back). This is the least common location for radiculopathy. The symptoms often follow a dermatomal distribution, and can cause pain and numbness that wraps around to the front of your body.

Lumbar radiculopathy: Lumbar radiculopathy describes a compressed nerve root in the lumbar spine (lower back). This is also referred to as sciatica because nerve roots that make up the sciatic nerve are often involved. The lower back is the area most frequently affected by radiculopathy.

Causes: Radiculopathy is caused by narrowing of the space where nerve roots exit the spine. The cause of the nerve compression can be mechanical, such as a herniated disc, osteophytes (bone spurs), or a thickening of the surrounding ligaments. Less common causes include tumor or infection, scoliosis causing nerves on one side of the spine to be compressed, and inflammation from trauma or degeneration. Symptoms: When a nerve root is compressed, it becomes inflamed. This results in several symptoms, which will vary depending on where in the spine the nerve root is pinched. These symptoms may include:

• sharp pain in the back, arms, legs or shoulders that may worsen with certain activities, even something as simple as coughing or sneezing

• weakness or loss of reflexes in the arms or legs

• numbness of the skin, “pins and needles,” or other abnormal sensations (paresthesia) in the arms or legs Diagnosis: A physical exam and physical tests may be used to check muscle strength and reflexes. If there is pain with certain movements, this may help a provider identify the affected nerve root. Imaging studies including x-rays, CT scans, or MRI scans, are used to better visualize the structures in the problem area. Nerve conduction studies and electromyography can be used to pinpoint whether the problem is neurological or muscular. Treatment: Radiculopathy treatment will depend on the location and the cause of the condition as well as many other factors. Nonsurgical treatment is typically recommended first and may include:

• medications such as NSAIDs or muscle relaxants to manage symptoms

• weight loss strategies to reduce pressure on the problem area

• physical therapy to strengthen muscles and prevent further damage

• steroid injections to reduce inflammation and manage pain

• in some cases, surgery will be recommended to reduce the pressure on the nerve root by widening the space where the nerve root exits the spine

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September 2020


Ankylosing Spondylitis Ankylosing spondylitis: Ankylosing spondylitis is an inflammatory disease (a form of arthritis) that, over time, can cause the vertebrae in the spine to fuse. This fusing makes the spine less flexible and can result in a hunched-forward posture. If the ribs are affected, it can be difficult to breathe deeply. Ankylosing spondylitis is a form of arthritis that affects the spine. Men are more likely to develop ankylosing spondylitis than are women. Onset generally occurs in late adolescence or early adulthood. Heredity plays a part as most people who have ankylosing spondylitis have the HLA-B27 gene.


ankylosing (of bones or a joint) be or become stiffened or united by ankylosis

ankylosis abnormal stiffening and immobility of a joint due to fusion of the bones.

spondylitis inflammation of the joints of the backbone.

Causes: Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. In particular, people who have a gene called HLA-B27 are at a greatly increased risk of developing ankylosing spondylitis. However, only some people with the gene develop the condition. Symptoms: Early signs and symptoms of ankylosing spondylitis might include pain and stiffness in the lower back and hips, especially in the morning and after periods of inactivity. Neck pain and fatigue also are common. Over time, symptoms might worsen, improve or stop at irregular intervals. The areas most commonly affected are:

• the joint between the base of the spine and the pelvis

• the vertebrae in the lower back

• the places where tendons and ligaments attach to bones, mainly in the spine, but sometimes along the back of the heel

• the cartilage between the breastbone Diagnosis: The provider will have the patient bend in different directions to test the range of motion in the spine. X-rays and MRIs may be ordered to check for changes in joints and bones. There are no specific labs to identify ankylosing spondylitis. Treatment: There is no cure for ankylosing spondylitis. The goal of treatment is to relieve pain and stiffness and prevent or delay complications and spinal deformity. Ankylosing spondylitis treatment is most successful before the disease causes irreversible damage to your joints. Treatment includes:

• NSAIDs to relieve inflammation, pain, and stiffness

• If NSAIDs are ineffective, a biologic medication such as a tumor necrosis factor (TNF) blocker or an interleukin-17 (IL-17) inhibitor may be started to help reduce pain, inflammation, stiffness, and tender or swollen joints

• Physical therapy for range of motion and stretching exercises

• Most people with ankylosing spondylitis do not need surgery, but surgery may be recommended for patients who have severe joint damage such that the joint needs to be replaced.

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September 2020


Spinal Stenosis

Spinal stenosis: Spinal stenosis is a narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck.

• Cervical stenosis. In this condition, the narrowing occurs in the part of the spine in the neck.

• Lumbar stenosis. In this condition, the narrowing occurs in the part of the spine in the lower back. This is the most common form of spinal stenosis.


stenosis a narrowing or constriction of the diameter of a bodily passage or orifice

Causes: Most spinal stenosis occurs when something happens to narrow the open space within the spine. Causes of spinal stenosis may include overgrowth of bone, herniated discs, thickened ligaments, tumors, and spinal injuries.

Symptoms: Symptoms vary depending on the location of the stenosis and which nerves are affected. Stenosis of the cervical spine:

• Numbness or tingling in a hand, arm, foot or leg

• Weakness in a hand, arm, foot or leg

• Problems with walking and balance

• Neck pain

• In severe cases, bowel or bladder dysfunction (urinary urgency and incontinence) Stenosis of the lumbar spine:

• Numbness or tingling in a foot or leg

• Weakness in a foot or leg

• Pain or cramping in one or both legs when standing for long periods of time or when walking, which usually eases when bending forward or sitting

• Back pain

Diagnosis: To diagnose spinal stenosis, the provider will ask about signs and symptoms, discuss the patient's medical history, and conduct a physical examination. Several imaging tests may be ordered including x-rays, MRIs, and CT scans to detect damage to discs and ligaments.

Treatment: Treatment for spinal stenosis depends on the location of the stenosis and the severity of signs and symptoms. Treatment may include:

• medications - pain medications, nightly doses of antidepressants to ease chronic pain, anti-seizure drugs to reduce pain caused by damaged nerves, and opiods

• physical therapy - to build strength and endurance. maintain the flexibility and stability of the spine, and improve balance

• steroid injections - injection of a steroid into the space around the impingement won't fix the stenosis, but it can reduce inflammation and relieve pain

• percutaneous image-guided lumbar decompression (PILD) - this decompression procedure involves using needle-like instruments to remove a portion of the thickened ligament in the back of the spinal column to increase spinal canal space and remove nerve root impingement

• alternative medicine - massage therapy, acupuncture, and chiropractic treatment may be used in conjunction with conventional medical treatments to relieve pain

• surgery - if other treatments have not helped or if symptoms are debilitating, then surgery may be performed to decompress the area of stenosis

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September 2020


Disc Herniation Disc Herniation: A herniated disc may also be referred to as a bulged, slipped, or ruptured disc. A spinal disc has a soft, jellylike center (nucleus) encased in a tougher, rubbery exterior (annulus). A herniated disc occurs when some of the nucleus pushes out through a tear in the annulus into the spinal canal.


herniation abnormal protrusion of an organ or other body structure through a defect or natural opening in a covering membrane, muscle, or bone

Causes: Disc herniation is most often the result of disc degeneration (a gradual, aging-related wear and tear). Sometimes using back muscles instead of leg and thigh muscles to lift heavy objects can lead to a herniated disc. Many people cannot pinpoint the cause of a herniated disc. Symptoms: Most herniated discs occur in the lower back, although they can also occur in the neck. Signs and symptoms depend on where the disc is situated and whether the disc is pressing on a nerve. They usually affect one side of the body. Symptoms include:

• Arm or leg pain - A herniated disc in the lower back may cause pain in the buttocks, thigh, calf, and sometimes part of the foot. A herniated disc in the neck causes pain in the shoulder and arm.

• Numbness and tingling, which radiates to the body part served by the affected nerve(s)

• Weakness - muscles served by the affected nerve(s) tend to weaken, causing stumbles or impacting the ability to lift or hold items

Diagnosis: A provider will perform a physical exam to check the back for tenderness, including a neurological exam to check for reflexes, muscle strength, and response to stimuli. In most cases, a physical exam and patient history are all that is needed to diagnose a herniated disc. If the provider needs to rule out another condition and/or needs to see which particular nerves are affected, then an x-ray, CT scan, MRI, or myelogram may be ordered. In addition, nerve conduction studies can help pinpoint the location of nerve damage. Treatment: Conservative treatment is the usual approach to treat a herniated disc. Measures include:

• over-the-counter pain medications for mild to moderate pain

• cortisone injections to relieve inflammation

• muscle relaxers to reduce muscle spasms

• opioids (short-term) for significant pain

• physical therapy to help with positions and exercises to minimize pain

• most often, a herniated disc does not require surgery; however, in severe cases where the nerve damage is causing debilitating symptoms, surgery will be considered

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September 2020


Spondylolisthesis Spondylolisthesis: Spondylolisthesis is a spinal condition that causes lower back pain. It occurs when vertebrae become weakened and fail to maintain their proper position in the spine. An injured vertebra shifts or slips forward onto the vertebra directly below it. It may put pressure on a nerve, which could cause lower back pain or leg pain.


spondylo spine or vertebrae

listhesis slipping, sliding or movement

Causes: There are various types of spondylolisthesis:

• Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth.

• Isthmic spondylolisthesis happens as a result of spondylolysis (stress fractures or cracks in vertebrae)

• Degenerative spondylolisthesis, the most common type, happens due to aging.

• Less common types of spondylolisthesis include those caused by injury, disease such as osteoporosis, or the result of spinal surgery

Symptoms: A person may not experience any symptoms of spondylolisthesis and not know they have the condition. When symptoms do occur, lower back pain is the most common one. The back pain may be accompanied by muscle spasms, back stiffness, difficulty walking or standing for long periods, pain when bending over. Diagnosis: In addition to obtaining a history and performing a physical exam, the provider will order spinal x-rays to see if a vertebrae is out of place as well as a CT scan or MRI to see soft tissue such as discs and nerves. Treatment: Treatment depends on the severity of the spondylolisthesis and the symptoms. Nonsurgical treatments include:

• rest - avoiding strenuous activities and sports

• medication - NSAIDs or other medications to relieve pain

• steroid injections - to relieve inflammation around the pinched nerve

• physical therapy - exercises to strengthen the abdomen and back

• bracing - to help stabilize the spine and limit movement If the spondylolisthesis is severe, then surgery will be considered to stabilize the spine where the vertebra has slipped, which in turn will alleviate pain and restore function. The surgery for spondylolisthesis typically involves spinal decompression, with or without fusion.

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September 2020


Spina Bifida Spina bifida: Spina bifida is a condition in which the spine and spinal cord do not form correctly. It is a congenital disease (birth defect) in which the spinal column is exposed. The term "spina bifida" means "cleft spine." The neural tube is the structure in a developing embryo that eventually becomes the baby's brain, spinal cord and the tissues that enclose them. In babies with spina bifida, a portion of the neural tube doesn't close or develop properly, causing defects in the spinal cord and in the bones of the spine. There are different forms of spina bifida:

• spina bifida occulta - Occulta means "hidden." This is mildest form of the condition as well as the most common, involving a small separation in one or more of the vertebrae.

• meningocele - This is the most rare form of spina bifida and occurs when the meninges protrudes out through the opening in the vertebra and forms a sac filled with fluid.

• myelomeningocele - Also known as open spina bifida, this is the most severe form of spina bifida. In this condition, the membranes and spinal nerves protrude through the spinal canal opening forming a sac and typically exposing tissues and nerves

Causes: Doctors aren't certain what causes spina bifida. It's thought to result from a combination of genetic, nutritional and environmental risk factors, such as a family history of neural tube defects and folate (vitamin B-9) deficiency. Symptoms: Signs and symptoms of spina bifida vary by type and severity.

• In spina bifida occulta, typically there are not any signs or symptoms because the spinal nerves are not involved. But you can sometimes see signs on the newborn's skin above the spinal defect, including an abnormal tuft of hair or a small dimple.

• In the severe type of spinal bifida, myelomeningocele, the spinal canal remains open along several vertebrae in the lower or middle back; both the membranes and the spinal cord or nerves protrude at birth, forming a sac.

Diagnosis: Typically, myelomeningocele is diagnosed before or right after birth. Spina bifida occulta requires an MRI or ultrasound to confirm the diagnosis. Treatment: Spina bifida treatment depends on the severity of the condition. Spina bifida occulta often doesn't require any treatment at all, but other types of spina bifida do.

• Prenatal surgery for spina bifida (fetal surgery) takes place before the 26th week of pregnancy. Surgeons repair the baby's spinal cord either through an open surgery or in select patients less invasively through ports in the uterus.

• Cesarean birth - If spina bifida myelomeningocele is detected before birth, a C-section is recommended to protect the exposed sac from trauma in the birth canal

• Post birth surgery - Myelomeningocele requires surgery to replace the spinal cord and exposed tissues inside the body and cover them with muscle and skin.

• Depending on the severity of spina bifida and the complications, treatment options may include walking and mobility aids and treatment and management of complications (orthopedic complications, GI issues, skin problems, etc.)

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September 2020


Scoliosis (Adolescent Idiopathic Scoliosis) Scoliosis (Adolescent Idiopathic Scoliosis): Scoliosis is the abnormal curvature of the spine in a "C" or "S" shape. There are several different types of scoliosis that affect children and adolescents. The most common type is "idiopathic," which means the exact cause is not known. Adolescent idiopathic scoliosis is an abnormal curvature of the spine that appears in late childhood or adolescence. Instead of growing straight, the spine develops a side-to-side curvature, usually in an elongated "S" or "C" shape; the bones of the spine are also slightly twisted or rotated. Sometimes scoliosis can be caused by underlying medical conditions, such as spina bifida, muscular dystrophy, and traumatic spinal cord injuries.

Spinal asymmetry vs scoliosis

Spinal asymmetry Scoliosis

• Mild spinal asymmetry is the presence of a slight curvature of the spine. It should be monitored regularly, as it can progress into scoliosis, particularly during growth spurts.

• Any curvature less than 10 degrees is considered normal variation in an individual (mild spinal asymmetry).

• Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty.

• Scoliosis is defined as curvature in the spine greater than 10 degrees.

Causes: Doctors do not know what causes the most common type of scoliosis — although it appears to involve hereditary factors, because the disorder tends to run in families. Less common types of scoliosis may be caused by neuromuscular conditions such as cerebral palsy or muscular dystrophy, birth defects affecting the development of the spine, or injuries to or infections of the spine. Symptoms of scoliosis include:

• uneven shoulders

• uneven waist

• one shoulder blade that appears more prominent than the other

• one hip higher than the other

• patient appears to be leaning to the side when standing straight.

• Scoliosis typically does not cause back pain. Diagnosis: A physical examination will be performed, during which the patient will stand and then bend forward from the waist to see if one side of the rib cage is more prominent than the other. In addition, x-rays can confirm diagnosis of scoliosis and reveal the severity of the spinal curvature. If a provider suspects that an underlying condition, such as a tumor, is causing the scoliosis, he or she may recommend additional imaging tests, such as an MRI. Treatment: Treatment will depend on the child’s age, how curved their spine is and the amount of growth still needed for the child’s bones to reach maturity. With mild cases of scoliosis providers will typically take a wait and see approach. In more severe cases children will wear a customized brace or undergo surgery to fuse vertebrae together in order to prevent additional deformity.

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September 2020


Medical Conditions - Hip

Trochanteric Bursitis Trochanteric Bursitis: Trochanteric bursitis is inflammation of the bursa (fluid-filled sac near a joint) at the outside (lateral) point of the hip known as the greater trochanter. When this bursa becomes irritated or inflamed, it causes pain in the hip. This is a common cause of hip pain.

Causes: Trochanteric bursitis can be caused due to falling on the hip, overuse of the hip (running stairs, climbing, standing for prolonged periods of time), incorrect posture, stress on the area, previous surgeries on the hip, related to other diseases/conditions. Symptoms include:

• pain on the outside of the hip and thigh or in the buttock.

• pain when lying on the affected side.

• pain when you press in or on the outside of the hip.

• pain that gets worse during activities such as getting up from a deep chair or getting out of a car.

• pain with walking up stairs. Diagnosis: The provider will perform a physical examination and ask the patient what movements cause pain. An x-ray may be ordered to rule out other conditions that can cause hip pain, and an ultrasound or MRI may be ordered to look at soft tissues. In some cases the provider will inject the trochanteric bursa with a pain-numbing drug. If the pain immediately stops, the patient most likely has trochanteric bursitis. Treatment: Treatment recommendations may include a combination of rest, splints, heat and cold application. More advanced treatment options include:

• Nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen.

• Corticosteroid injections given by a healthcare provider. Injections work quickly to decrease the inflammation and pain.

• Physical therapy that includes range of motion exercises and splinting. This can be very beneficial.

• Surgery, when other treatments are not effective.

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September 2020


Avascular Necrosis Avascular Necrosis: Avascular necrosis is the death of bone tissue due to interruption of blood supply to the area. Also referred to as aseptic necrosis, bone infarction, or osteonecrosis, this condition can lead to tiny breaks in the bone and the bone's eventual collapse. A broken bone or dislocated joint can interrupt the blood flow to a section of bone. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake.

Causes: Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by joint or bone trauma, cancer treatments involving radiation, fatty deposits in blood vessels, and certain diseases such as sickle cell anemia and Gaucher disease. Symptoms: Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, the affected joint might hurt only when weight is put on it. Eventually, the pain might be felt even when the patient is lying down. Pain can be mild or severe and usually develops gradually. Besides the hip, the areas likely to be affected by avascular necrosis are the shoulder, knee, hand and foot. Diagnosis: During a physical exam the provider will press around joints, looking for tender areas, and test the range of motion of the joints. Imaging tests can help pinpoint the source of pain and rule out other conditions. Common imaging tests ordered to check for avascular necrosis include x-rays, MRI and CT scans, and bone scans. Treatment: In the early stages of avascular necrosis, conservative measures will be employed including:

• medications, especially NSAIDs, to relieve pain

• cholesterol-lowering drugs to help prevent blockages

• blood thinners if the patient has any clotting disorders

• rest to reduce weight and stress on the affect bone

• exercise to maintain or improve range of motion in the joint

• electrical stimulation to encourage the body to grow new bone to replace the damaged bone

If the avascular necrosis is advanced, then surgery may be recommended. Options include:

• core decompression, which removes part of the inner layer of a bone

• bone transplant (graft) from a healthy bone taken from elsewhere in the body

• bone reshaping (osteotomy) to help shift weight off the damaged bone

• joint replacement

• regenerative medicine treatment, such as stem cell insertion into the damaged bone

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September 2020


Hip Dysplasia Hip Dysplasia: Hip dysplasia is the medical term for a hip socket that doesn't fully cover the ball portion of the upper thighbone. This allows the hip joint to become partially or completely dislocated. Hip dysplasia is usually the end result of developmental dysplasia of the hip (DDH), meaning that most people with hip dysplasia are born with the condition. It can also develop in early childhood.

Causes: At birth, the hip joint is made of soft cartilage that gradually hardens into bone. During the final month before birth, the space within the womb can become so crowded that the ball of the hip joint moves out of its proper position. The risk of hip dysplasia is higher in babies born in the breech position, and it also tends to be more common in girls. Symptoms: Signs and symptoms vary by age group. In infants, one leg will look to be longer than the other. Once a child begins walking, a limp may develop. During diaper changes, one hip may be less flexible than the other. In teenagers and young adults, hip dysplasia can cause painful complications such as osteoarthritis or a hip labral tear. This may cause activity-related groin pain. In some cases, the patient might experience a sensation of instability in the hip. Diagnosis: During well-baby visits, providers typically check for hip dysplasia by moving an infant's legs into a variety of positions that help indicate whether the hip joint fits together well. Mild cases of hip dysplasia can be difficult to diagnose and might not start causing problems until the patient is a young adult. If the provider suspects hip dysplasia, he or she might suggest imaging tests, such as x-rays or magnetic resonance imaging (MRI). Treatment: Hip dysplasia treatment depends on the age of the affected person and the extent of the hip damage. Infants are usually treated with a soft brace, such as a Pavlik harness, that holds the ball portion of the joint firmly in its socket for several months. This helps the socket mold to the shape of the ball. The brace doesn't work as well for babies older than 6 months. Instead, the doctor may move the bones into the proper position and then hold them there for several months with a full-body cast. Sometimes surgery is needed to fit the joint together properly.

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September 2020


Medical Conditions - Knee

ACL Injury ACL Injury: One of the most common knee injuries is an ACL (anterior cruciate ligament) sprain or tear. ACL injuries often happen during sports and fitness activities that can put stress on the knee. When the ligament is damaged, there is usually a partial or complete tear of the tissue. A mild injury may stretch the ligament but leave it intact.

Causes: An injury to the ACL can be caused by:

• sudden stopping

• direct impact on the ligament

• changing direction suddenly

• slowing down while running

• landing incorrectly from a jump Symptoms of an ACL injury include:

• a loud "pop" or a "popping" sensation in the knee

• severe pain and inability to continue activity

• rapid swelling

• loss of range of motion

• a feeling of instability or "giving way" with weight-bearing Diagnosis: The provider will perform a physical exam on the knee to check for tenderness and range of motion. If the exam alone cannot confirm an ACL injury, then tests may be ordered including x-rays to rule out a fracture and MRIs or ultrasounds to view injury to soft tissues. Treatment: Prompt treatment with RICE - rest, ice, compression, elevation - can help reduce pain and swelling. Medical treatment for an ACL injury almost always involves physical therapy to restore range of motion and strengthen muscles. Surgery may be recommended if more than one ligament or the meniscus is also involved or if the injury is causing the knee to buckle during everyday activities.

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September 2020


Medial/Lateral Meniscus Tear Medial/Lateral Meniscus Tear: The menisci act as "shock absorbers" between the femur and tibia. There are 2 menisci in each knee:

• lateral meniscus (situated on the outside of the knee)

• medial meniscus (situated on the inside of the knee)

Meniscal tissue is not self repairing. The most common type of meniscal tear is degenerative. This means that it occurred due to wear and tear over time. However, meniscal tears are also often caused by an injury.

Causes: A torn meniscus can result from any activity that causes a person to forcefully twist or rotate your knee, such as aggressive pivoting or sudden stops and turns. Even kneeling, deep squatting or lifting something heavy can sometimes lead to a torn meniscus. In older adults, degenerative changes of the knee can contribute to a torn meniscus with little or no trauma. Symptoms: A torn meniscus may prompt the following signs and symptoms in the knee:

• A popping sensation

• Swelling or stiffness

• Pain, especially when twisting or rotating the knee

• Difficulty straightening the knee fully

• Feeling as though the knee is locked in place when trying to move it

• Feeling of the knee giving way Diagnosis: A torn meniscus often can be identified during a physical exam. A torn meniscus often can be identified during a physical exam. Imaging studies may be ordered. Because a torn meniscus is made of cartilage, it will not show up on x-rays; however, x-rays can help rule out other problems with the knee that cause similar symptoms. An MRI scan is the best imaging study to detect a torn meniscus. Treatment: Tears associated with arthritis often improve over time with treatment of the arthritis, so surgery usually isn't indicated. Many other tears that aren't associated with locking or a block to knee motion will become less painful over time, so they also don't require surgery. Conservative treatments include:

• rest, including avoiding activities that aggravate knee pain

• ice to reduce swelling

• over-the-counter medications to relieve pain

• physical therapy to strengthen the muscles in the knee and leg If conservative treatments are not successful, surgery can sometimes be effective to repair a torn meniscus. In patients with advanced degenerative arthritis, a knee replacement may be recommended.

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September 2020


Medical Conditions - Foot & Ankle

Trimalleolar Ankle Fracture Trimalleolar ankle fracture: A trimalleolar ankle fracture is a fracture that involves the lateral malleolus, medial malleolus, and distal posterior tibia (also referred to as the posterior malleolus). This trauma is sometimes accompanied by ligament damage and dislocation.

Causes: A trimalleolar ankle fracture can result from a number of injuries including a sudden impact against the ankle, tripping/falling, rolling/twisting the ankle, sports injuries, as well as weakened ankle ligaments that cannot support complete weight-bearing. Symptoms include:

• severe pain and tenderness in the area

• inability to walk

• difficulty or inability to put weight on the ankle

• bruising

• ankle deformity

• swelling that is often severe Diagnosis: X-rays are usually required to determine whether there is a broken bone as opposed to a soft-tissue injury like a sprain, since ankle sprains and breaks have similar symptoms. Other radiology imaging, such as a CT scan or MRI, may be needed to determine the full scope of the injury. Treatment: Surgery is usually the recommended treatment for a trimalleolar ankle fracture to stabilize the ankle and realign the bones so they may heal. Nonsurgical treatment would be recommended only if surgery would pose too high a risk for the patient due to other health conditions.

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September 2020


Plantar Fasciitis Plantar Fasciitis: Plantar fasciitis is the inflammation of the fibrous tissue (called a fascia) along the bottom of the foot that connects the heel (calcaneus) to the toes (phalanges). Plantar fasciitis is common in people who are active in sports, especially runners.


plantar pertaining to the sole of the foot

fasciitis inflammation of a fascia

Causes: The plantar fascia is in the shape of a bowstring, supporting the arch of the foot and absorbing shock when walking. If tension and stress on this bowstring become too great, small tears can occur in the fascia. Repeated stretching and tearing can irritate or inflame the fascia. Symptoms include:

• A stabbing pain in the bottom of the foot near the heel.

• The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or when you get up after sitting.

• The pain is usually worse after exercise, not during it. Diagnosis: Plantar fasciitis is diagnosed based on a patient's medical history and a physical examination of the foot. Usually no tests are necessary, although an x-ray or MRI may be ordered to make sure another problem, such as a stress fracture, is not causing the patient any pain. Treatment includes:

• rest

• ice

• over-the-counter pain relievers (Aleve, Advil, Motrin, etc.)

• physical therapy

• night splints

• orthotics

• steroid injections

• Tenex procedure

• plantar fascia release

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September 2020


Achilles Tendinitis & Achilles Tendon Rupture

Achilles Tendinitis: Achilles tendinitis is an overuse injury of the Achilles tendon, the band of tissue that connects calf muscles at the back of the lower leg to the heel bone. Achilles tendinitis most commonly occurs in runners who have suddenly increased the intensity or duration of their runs. The Achilles tendon is the largest tendon in the body.

Fun fact: The Achilles tendon is named after the ancient Greek mythological figure Achilles because it lies at the only part of his body that was still vulnerable after his mother had dipped him (holding him by the heel) into the River Styx.


tendinitis inflammation of a tendon

Causes: Achilles tendinitis is caused by repetitive or intense strain on the Achilles tendon, the band of tissue that connects the calf muscles to the heel bone. This tendon is used when walking, running, jumping, or pushing up on the toes. The structure of the Achilles tendon weakens with age, which can make it more susceptible to injury — particularly in people who may participate in sports only on the weekends or who have suddenly increased the intensity of their running programs.

Symptoms include:

• discomfort or swelling in the back of the heel that gets worse during activity

• tight calf muscles

• severe pain the day after exercising

• tendon thickening

• bone spur, or insertional tendinitis

• limited range of motion when flexing the foot

• skin on the heel overly warm to the touch

Diagnosis: Achilles tendinitis is diagnosed based on a patient's medical history and a physical examination of the foot and heel. Imaging tests may help confirm Achilles tendinitis, although they are usually not necessary. If ordered, tests may include an x-ray, MRI, or an ultrasound.

Treatment includes:

• reducing physical activity

• RICE (rest, ice, compression, and elevation) method

• gentle stretching exercises

• eccentric strengthening

• bilateral heel drop

• single leg heel drop


• anti-inflammatory medication, such as aspirin (Bufferin) or ibuprofen (Advil)

• wearing a shoe with a built-up heel to take tension off the Achilles tendon

• cortisone injections

• gastrocnemius recession

• if non-surgical treatments do not help, surgery may be considered to repair the Achilles tendon

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September 2020


Achilles Tendinitis & Achilles Tendon Rupture

Achilles Tendon Rupture: An Achilles tendon rupture is a tearing and separation of the tendon fibers so that the tendon can no longer function properly. This mainly occurs in people who play recreational sports, although it can happen to anyone. If the Achilles tendon is overstretched, it can tear (rupture) completely or just partially.

Causes: Ruptures often are caused by a sudden increase in the stress on the Achilles tendon. Common examples include increasing the intensity of sports participation, especially in sports that involve jumping; falling from a height; or stepping into a hole. Symptoms of an Achilles tendon rupture include:

• a "pop" may be felt in the back of the lower leg followed by an immediate sharp pain and swelling that can affect the ability to ambulate properly

• inability to bend the foot downward or "push off" the injured leg when ambulating

• inability to stand on the toes on the injured leg

• a feeling of having been kicked in the calf

• pain, possibly severe, and swelling near the heel Diagnosis: During the physical exam, the medical provider will inspect the lower leg for tenderness and swelling. They might be able to feel a gap in the tendon if it has ruptured completely. Various flexion tests may be performed. An ultrasound or MRI may be ordered to determine if the Achilles tendon is completely or only partially ruptured. Treatment includes:

• rest

• resting the tendon by using crutches

• ice therapy



• a walking boot with heel wedges or a cast with the foot in plantar flexion

• surgical Achilles tendon repair which involves reconnecting the calf muscles to the calcaneus

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September 2020


Hallux Valgus (Bunion)

Hallux Valgus (Bunion): Hallux valgus is colloquially referred to as a "bunion" and is a painful bump that forms along the joint of the hallux (great toe). A bunion happens over time and actually reflects a change in the anatomy of the foot. Bunion is derived from a Greek word meaning "turnip," referring to its hard consistency.


hallux big toe

valgus toward the midline of the foot

Causes: Anyone can get bunions, but they are more common in women. People with flat feet are more likely to get bunions. Bunions may be hereditary, as they often run in families. This suggests that people may inherit a faulty foot shape. In addition, footwear that does not fit properly may cause bunions. Symptoms: include:

• bump along the base of the hallux

• burning sensation

• numbness

• difficulty with ambulation

• discomfort or pain in the area

• swelling

• restricted motion Tailor’s Bunion (Bunionette): There is also a condition called tailor’s bunion or bunionette. This type of bump differs from a bunion in terms of the location. A tailor’s bunion is found near the base of the little toe on the outside of the foot..

Causes: The deformity received its name centuries ago, when tailors sat cross-legged all day with the outside edge of their feet rubbing on the ground. This constant rubbing led to a painful bump at the base of the little toe. Symptoms: The symptoms of tailor’s bunions include redness, swelling and pain at the site of the enlargement. These symptoms occur when wearing shoes that rub against the enlargement, irritating the soft tissues underneath the skin and producing inflammation. Diagnosis: Generally, observation is enough to diagnose a bunion, as the bump is obvious on the side of the foot or base of the big toe. However, your physician may order x-rays that will show the extent of the deformity of the foot. Treatment for bunions includes:

• ice therapy to provide relief from inflammation and pain

• shoe modifications (proper fit and adequate toe room)

• putting bunion pads over the bunion to cushion the pain



• shoe inserts / orthotics

• a bunionectomy might be recommended in cases where the patient is in extreme pain or has trouble walking

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September 2020


Haglund Deformity Condition: Haglund deformity is a bony bump that appears on the back of the heel. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa (a fluid-filled sac between the tendon and bone). Haglund deformity is often called “pump bump” because the rigid backs of pump-style shoes can create pressure that aggravates the enlargement when walking.

"Haglund" is an eponym name. The condition is called Haglund deformity because it was first described by Patrick Haglund in 1927.

Causes: Shoes with rigid backs, such as pump-style shoes, men's dress shoes, and ice skates all can contribute towards this irritation. In addition to footwear, other factors that contribute to Haglund deformity include having a high-arched foot, a tight Achilles tendon, or a tendency to walk on the outside of the heel. Symptoms include:

• a noticeable bump on the posterior aspect (back) of the heel

• pain where the Achilles tendon attaches to the heel

• redness and swelling

• swelling in the bursa, which is the fluid-filled sac at the back of the heel Diagnosis: Haglund deformity may be difficult to diagnose because the symptoms are similar to those associated with other foot issues, such as Achilles tendinitis. The provider might be able to diagnose the condition based on the physical appearance of a patient's heel. An x-ray may be ordered to check the heel bone. Treatment: or Haglund deformity usually focuses on relieving pain and taking pressure off the heel bone. Treatment measures may include:

• wearing open-backed shoes and other shoe modifications

• ice therapy to reduce swelling

• over-the-counter NSAIDs

• stretching


• heel pads and heel lifts


• orthotics

• wearing an immobilizing boot or cast

• surgery to remove the deformity

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September 2020


Diabetic Foot Ulcer

Diabetic neuropathy is a type of nerve damage that can occur in patients with diabetes. High blood sugar (glucose) can injure nerves throughout the body. In particular, diabetic neuropathy most often damages nerves in the legs and feet, necessitating care from a podiatrist or physician to manage the diabetic foot issues, including toe nail trimming, diabetic foot checks, and diabetic foot ulcers.

Diabetic Foot Ulcer: Text

Causes: Foot ulcers are a common complication of poorly controlled diabetes, forming as a result of skin tissue breaking down and exposing the layers underneath. These open sores are most commonly located under the big toe and on the ball of the foot. Symptoms include:

• drainage in the socks is typically the first symptom

• redness, swelling, and odor is common depending on the stage of the ulcer

• black tissue may surround the ulcer, which forms because of an absence of healthy blood flow to the area around the ulcer

• pain is not common as many people have developed the inability to feel pain

• due to diabetic neuropathy, many patients may not notice foot ulcers until they become infected Diagnosis: A diabetic ulcer can be diagnosed by a visual inspection, since the ulcer is an open sore that is clearly visible. However, x-rays or MRI scans may be ordered to assess the extent of the damage caused by an ulcer. If there are signs of infection, a blood test will be performed to confirm or rule out an infection. Treatment includes the following:

• Staying off the feet to prevent pain and ulcers (called off-loading) in addition to compression wraps, foot braces, diabetic shoes, orthotics and bunion pads.

• Antibiotics are prescribed for infected ulcers, and wound debridement is often necessary to remove dead skin and clean the area.

• Topical treatments include dressings that contain silver or silver sulfadiazine, polyhexamethylene biguanide (PHMB) gel, iodine, and medical grade honey.

• Hyperbaric oxygen therapy can be used to decrease the wound area and promote healing

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September 2020


Talipes Equinovarus (Clubfoot)

Talipes Equinovarus (Clubfoot): Clubfoot (talipes equinovarus) is a congenital foot abnormality of one or both feet in which the foot is pulled downwards and inwards. The middle section of the foot is also twisted inwards so the foot appears quite short and wide. It cannot be gently moved into a normal foot position. The baby's foot is kept in this position because the Achilles tendon at the back of the baby's heel is very tight, and the tendons on the inside of their leg have become shortened. If nothing is done to correct the problem, as the baby learns to stand, they will not be able to put the sole of their foot flat on the ground. In most cases, the baby has no other problems apart from the talipes equinovarus. However, in around 1 in 5 babies born with talipes, there is also another problem, which may include spina bifida or cerebral palsy.


talipes ankle and foot

equinovarus refers to the position that the foot is in:

• equinus means the foot points downwards at the ankle

• varus means the heel of the foot is turned inwards

Causes: The cause of clubfoot is unknown (idiopathic), but it may be a combination of genetics and environment. Symptoms include the following physical appearances:

• anterior side of foot adducted and inverted

• heel drawn up

• lateral side of foot convex

• medial aspect of foot concave Diagnosis: Most commonly, a doctor recognizes clubfoot soon after birth just from looking at the shape and positioning of the newborn's foot. It is possible to clearly see most cases of clubfoot before birth during a routine ultrasound exam. While nothing can be done before birth to solve the problem, knowing about the condition may give the parents time to learn more about clubfoot and get in touch with appropriate health experts, such as a pediatric orthopedic surgeon. Treatment: The Ponseti Method is the preferred treatment to correct clubfoot. This involves the specialist gently manipulating (holding, stretching and moving) the child's foot with their hands, into a position in which the foot deformity is corrected as much as possible. This is not painful or uncomfortable for the child. Once in this position, a plaster cast is put on to hold the child's foot in position. This plaster cast usually goes all the way from the child's toes to their groin area. After one week, the plaster cast is removed, the child's foot is manipulated again, and a plaster cast is put back on with the child's foot in the new position. After another week, this procedure is repeated. As each week goes by, usually the child's foot is able to be moved into a position that becomes closer and closer to a normal foot position. After around six weeks of repeated manipulation and plaster casting of the foot, there is usually good progress and the foot position has improved. At this stage, an Achilles tenotomy is usually recommended to release the tight Achilles tendon so that the heel can drop down. After this, the foot is put in a final plaster cast for several weeks. The child will then need to wear some special boots that are connected together with a bar. They will need to wear these for 23 hours a day for three months. After this, they generally just need to wear the 'boots and bar' at night or during sleep periods until they are 4 years old.

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September 2020


Hammer, Mallet, and Claw Toes Hammer, Mallet, and Claw Toes: Normally, the toes lie flat. But pressure on the toes or the front of the foot can cause one or more joints to bend. This curls the toe. Toes that stay curled are called hammer toes, mallet toes, or claw toes, depending on which joints are bent. Hammer, mallet, and claw toes occur most often in the longest of the four smaller toes. Causes: The most common cause is a muscle/tendon imbalance. This imbalance, which leads to a bending of the toe, results from mechanical (structural) changes in the foot that occur over time in some people. Hammer toes, mallet toes, and claw toes may be aggravated by shoes that don’t fit properly, and they may result if a toe is too long and is forced into a cramped position when a tight shoe is worn. Occasionally, the deformity is the result of an earlier trauma to the toe. In some people, the condition may be inherited. Joints of the Toes DIP - distal interphalangeal joint PIP - proximal interphalangeal joint MTP - metatarsophalangeal joint

Hammer toe: With a hammer toe, the middle joint (the MPJ joint) is bent, causing a curling of the toe. Hammer toe is most common in the second toe, but it can occur in any of the smaller toes. Hammer toes are often present along with a bunion deformity.

Mallet toe: With a mallet toe, the joint nearest the tip of the toe (the DIP joint) is bent. This deformity gives the toe a mallet-like appearance at the end of the toe.

Claw toe: With a claw toe, the joint at the base of the toe (the MTP joint) is bent up. The middle joint (the MPJ joint) is bent down. This results in a claw-like bending which can often dig in to the sole of the foot.

Symptoms: In addition to the obvious curling of the toes as shown in the diagrams above, hammer toes, mallet toes, and claw toes may cause other issues including:

• difficulty walking

• corns or calluses

• difficult ambulation

• inability to wiggle or flex the toes

• pain in the toe or in the ball of the foot

• inflammation, redness, or a burning sensation

• in severe cases, open sores may form

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September 2020


Diagnosis: A provider can diagnose hammer toe, mallet toe or claw toe by examining the foot. X-rays may be ordered to further evaluate the bones and joints of the feet and toes. Treatment includes:

• over-the-counter medications, such as ibuprofen, to reduce pain and inflammation

• pads and/or orthotics to reposition the toe and relieve pressure and pain

• medications to treat corns and calluses

• stretching and strengthening exercises

• splinting of the affected toe

• shoes that allows extra space for toes

• corticosteroid injections to ease pain and inflammation

• surgery to release the tendon that is preventing the toe from lying flat; in some cases, a piece of bone may be removed as well to reposition and straighten the toe

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September 2020


Medical Conditions - General

Osteoarthritis Osteoarthritis: Osteoarthritis is the most common form of arthritis. It occurs when the protective cartilage that cushions the ends of the bones wears down over time. Osteoarthritis is also referred to as degenerative joint disease (DJD). Although osteoarthritis can damage any joint, the disorder most commonly affects joints in your hands, knees, hips and spine.

Causes: Osteoarthritis has often been referred to as a "wear and tear" disease since the risk of osteoarthritis increases with age. Other risk factors that contribute towards osteoarthritis include obesity, previous joint injuries, repeated stress on a joint, and genetics. Symptoms: Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

• Pain during or after movement

• Stiffness, especially after awakening or after being inactive

• Tenderness in affected joints

• Loss of flexibility of affected joints

• Grating sensation, popping, or cracking of affected joints

• Bone spurs

• Swelling of soft tissue around the joint Diagnosis: During a physical exam, a provider will check affected joints for tenderness, swelling, redness and flexibility. To get pictures of the affected joint, x-rays and MRIs may be recommended. Although cartilage does not show up on x-ray images, cartilage loss is revealed by a narrowing of the space between the bones. Analyzing blood or joint fluid can also help confirm the diagnosis. Treatment: Osteoarthritis can't be reversed, but treatments can reduce pain and help improve movement, including:

• medications, including acetaminophen, NSAIDs, and Cymbalta

• physical therapy to help strengthen the muscles around the affected joints and occupational therapy to avoid placing extra stress upon affected joints

• cortisone injections to relieve pain

• lubrication injections of hyaluronic acid for pain relief

• realignment of bones via an osteotomy

• joint replacement therapy

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September 2020


Cerebral Palsy Cerebral palsy: Cerebral palsy is a group of disorders that affect movement and muscle tone or posture. It's caused by damage that occurs to the immature brain as it develops, most often before birth. Signs and symptoms appear during infancy or preschool years. Delays in meeting normal milestones is one early sign of the onset of this condition. In general, cerebral palsy causes impaired movement associated with abnormal reflexes, floppiness or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteady walking, or some combination of these. Cerebral palsy's effect on function varies greatly. Some affected people can walk; others need assistance. Some people show normal or near-normal intellect, but others have intellectual disabilities. Epilepsy, blindness or deafness also might be present. Because the care for adults with cerebral palsy has not been well documented, many times we will see that the orthopedic care for adult cerebral palsy cases is deferred to a pediatric specialist.

Causes: Cerebral palsy is caused by an abnormality or disruption in brain development, most often before a child is born. In many cases, the cause isn't known, but factors that can lead to problems with brain development include gene mutations, infections and trauma in utero or as a newborn, low birth weight, and maternal factors/infections.

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September 2020


Symptoms: Cerebral palsy can affect the whole body, or it might be limited primarily to one limb or one side of the body. The brain disorder causing cerebral palsy doesn't change with time, so the symptoms usually don't worsen with age. Movement and coordination problems associated with cerebral palsy include:

• Variations in muscle tone, such as being either too stiff or too floppy

• Stiff muscles and exaggerated reflexes (spasticity)

• Stiff muscles with normal reflexes (rigidity)

• Lack of balance and muscle coordination (ataxia)

• Tremors or involuntary movements

• Slow, writhing movements

• Delays in reaching motor skills milestones, such as pushing up on arms, sitting up or crawling

• Favoring one side of the body, such as reaching with one hand or dragging a leg while crawling

• Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing, a wide gait or an asymmetrical gait

• Excessive drooling or problems with swallowing

• Difficulty with sucking or eating

• Delays in speech development or difficulty speaking

• Learning difficulties

• Difficulty with fine motor skills, such as buttoning clothes or picking up utensils

• Seizures Diagnosis: Signs and symptoms of cerebral palsy can become more apparent over time, so a diagnosis might not be made until a few months after birth. When cerebral palsy is suspected, a referral may be made to a specialist trained in treating children with brain and nervous system conditions. Brain scans such as MRI or cranial ultrasounds can reveal areas of damage or abnormal development in the brain. If a child is diagnosed with cerebral palsy, testing for other conditions will be conducted including tests to detect problems with vision, hearing, speech, intellect, development and movement. Treatment:: Children and adults with cerebral palsy require long-term care with a medical care team. Treatment plans often include:

• medications and/or muscle or nerve injections to lessen muscle tightness

• numerous therapy regiments including physical therapy to help with mobility, occupational therapy to help with activities of daily living, speech and language therapy, and recreational therapy

• surgery may be needed to loosen muscle tightness or correct bone abnormalities

• alternative medicine may be used in addition to more conventional treatment, such as hyperbaric oxygen therapy or resistance exercise training using special clothing

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Charcot-Marie-Tooth Disease (CMTD) Charcot-Marie-Tooth Disease: Charcot-Marie-Tooth disease is a group of inherited disorders that cause nerve damage. This damage is mostly in the arms and legs (peripheral nerves), leading to muscle weakness and some loss of sensation in the arms, legs, hands, and feet. These symptoms often first appear during adolescence or early adulthood but can develop later in life as well. Charcot-Marie-Tooth disease is also called hereditary motor and sensory neuropathy.

Causes: Charcot-Marie-Tooth disease is an inherited, genetic condition. It occurs when there are mutations in the genes that affect the nerves in the feet, legs, hands and arms. Sometimes, these mutations damage the nerves. Other mutations damage the protective coating that surrounds the nerve (myelin sheath). Symptoms: Signs and symptoms of Charcot-Marie-Tooth disease may include:

• weakness in the legs, ankles and feet

• loss of muscle bulk in the legs and feet

• high foot arches

• curled toes (hammer toes)

• decreased ability to run

• difficulty lifting the your foot at the ankle (foot drop)

• awkward or higher than normal step (gait)

• frequent tripping or falling

• decreased sensation or a loss of feeling in the legs and feet Diagnosis: During a physical exam, the provider will examine the extremities to look for muscle weakness, decreased muscle bulk, reduced reflexes, sensory loss, and deformities. Testing may be ordered including nerve conduction studies, electromyography, nerve biopsies, and genetic testing. Treatment: There is no cure for Charcot-Marie-Tooth disease; however, the disease generally progresses slowly, and it doesn't affect expected life span. Treatment include:

• medications to control pain

• physical therapy to help strengthen muscles and occupational therapy to help with activities of daily living

• orthotic devices to help with mobility and to prevent injury

• if foot deformities are severe, corrective foot surgery may help reduce pain and improve the ability to walk

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Treatment

Medications Medication Treatment The type of medication prescribed depends on the condition being treated. In addition, factors such as age, gender, weight, and other comorbidities will be taken into account. Medications prescribed will serve to alleviate pain and swelling, treat an infection, or control an underlying condition that is contributing to an orthopedic disease. Several different categories (classifications) of drugs are used to treat the signs, symptoms, and diseases of the musculoskeletal system. Drug Categories To classify a drug means to group compounds with similar characteristics, modes of action, effects on body systems, and indications for use in order to facilitate comparisons between them. The class of the drug is important. Many interactions and reactions with other drugs are often common with drugs of the same class. Some examples of the categories of drugs used to treat musculoskeletal disorders are listed in the table below.

Category Indications for Use Medications examples (Brand Name, generic)

analgesics inflammation & pain; minor injuries, muscle strains, tendinitis, bursitis, etc.

Bayer (aspirin) Ecotrin (aspirin) Tylenol (acetaminophen)

anti-epileptic primary use - epilepsy secondary use - relieve tremors

Mysoline (primidone)

beta-blockers primary use - hypertension secondary use - relieve tremors

Inderal (propranolol)

bone resorption inhibitor drugs

inhibit bone from being broken down (ex: treat osteoporosis)

Fosamax (alendronate sodium) Miacalcin (calcitonin-salmon)

corticosteroids Inflammation Celestone (betamethasone) Florinef (fludrocortisone) Prelone (prednisolone) Solu-Medrol (methylprednisolone)

muscle relaxants muscle spasm and stiffness, muscle stains baclofen Flexeril (cyclobenzaprine) Robaxin (methocarbamol) Skelaxin (metaxalone) Soma (carisoprodol)

nonsteroidal anti-inflammatory drugs (NSAIDs)

inflammation, pain, fever, minor injuries Aleve (naproxen) Motrin (ibuprofen)

SNRIs primary use- depression, anxiety secondary use- fibromyalgia, peripheral neuropathy

Cymbalta (duloxetine) Effexor XR (venlafaxine)

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Therapy - Physical, Occupational, Recreational Physical Therapy The role of physical therapy is to help regain and restore the pain-free and comfortable movement and overall health that a person experienced prior to an injury, illness or disability.

The type and extent of physical therapy depends entirely on a patient's condition and needs. If the patient is an athlete looking to recover and get back in the lineup, they may need more aggressive conditioning to prepare their body to handle the strain of their sport. If a patient is suffering with general chronic pain, therapy will be designed to relax tightened tissues and decrease inflammation. Most treatment plans do involve some form of exercise, but physical therapy can be tailored to a patient's specific situation. Physical therapy treatments may include:

• stretching exercises

• strengthening exercises

• flexibility training

• joint mobilization

• manual therapy

• shockwave treatment

• therapeutic ultrasound

• hydrotherapy Occupational Therapy

The primary goal of occupational therapy is to enable people to participate in the activities of everyday life and to live as independently as possible.

In occupational therapy, occupations refer to the things people need to, want to and are expected to do in their homes, in a job, or within the community. Examples include dressing, eating, bathing, toileting, writing, etc. The occupational therapist will look at how a patient does any kind of activity or task. Then they come up with a plan to improve the way the patient performs that task to make it easier or less painful. Recreational Therapy Recreational therapy, also known as therapeutic recreation, is a systematic process that utilizes recreation and other activity-based interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being.

Recreational therapy is not all fun and games. There is a purpose behind the activities that are specifically targeted to each patient. When individuals are suffering from a physical injury or mental illness, they need help learning, not only how to live with their disability, but to enhance their quality of life by reducing the isolation that patients experience and helping them to participate in leisure activities. These activities include arts and crafts, music, spending time with animals, sports, and drama.

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Assistive Devices Orthotics What comes to mind for many people when they hear the word "orthotics" is a shoe insert. Certainly, many problems in the feet and ankles, from overuse injuries to biomechanical deficiencies, can be helped by adding support and stabilization to the lower limbs by the use of orthotics. While "orthotics" conjures up the image of inserts for a shoe, an orthotic may refer to a support, brace, splint or other device used to support, align, prevent, or correct the function of movable parts of the body. Examples of orthotics other than inserts include:

• Brace: A brace is a supportive garment that is worn for protection or for stabilization while allowing the injured body part to heal from an injury such as a sprain.

• Splint: Splints, also sometimes called "half casts," immobilize a body part. They provide less support than casts, but they are easy to loosen, tighten or remove using the Velcro straps, allowing the splint to accommodate any changes in the swelling of the body part ensconced within the splint.

• Cast: Casts are orthopedic devices doctors apply to support broken, fractured or injured bones and/or joints. They immobilize the injured body part so it stays completely still while it heals.

• Gait plates: Gait plates are a device that are put into the footwear of a child who suffers from an in-toe or out-toeing gait. Gait plates work by helping to alter the function of a child’s leg, thus changing the way the child stands and the way they walk during the gait cycle.

• Night bars. This is a splint used in the correction of clubfoot and metatarsus adductus. The splint consists of a bar (the length of which is the distance between the baby’s shoulders) with high-top open-toed shoes attached at the ends of the bar in about 70 degrees of external rotation.

• Collar. A cervical collar, also known as a neck brace or C collar, is used to support the spinal cord and head. These collars are a common treatment option for neck injuries, neck surgeries, and some instances of neck pain.

Ambulatory Assistive Devices Ambulatory assistive devices refer to walking aids such as canes, crutches, and walkers. The purpose of an ambulatory assistive device is to help a patient with ambulation, promote stability, provide augmentation of muscle action, and result in the reduction of weight-bearing load. Other Assistive Devices Assistive devices are tools that help make certain daily activities easier to do. They can help a patient with daily activities such as bathing, grooming, dressing, writing, reading, or eating. Examples of other assistive devices include:

• magnifying aids to help with vision problems

• tub or shower grab bars

• button or zipper hooks to help with dressing

• special lifts to help rise from a seated position

• devices to help open doors

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Nonsurgical Treatments & Clinical Procedures There are numerous nonsurgical and therapeutic treatments that can be used to treat conditions of the musculoskeletal system. Examples include:

• aspiration (also known as arthrocentesis): a procedure to remove fluid from the space around a joint

• closed reduction of fracture: the treatment of bone fractures by placing the bones in proper position (reducing the fragments without surgery); alignment is stabilized with the application of an external device to protect and hold the fracture while healing. Examples of external stabilization devices include:

o traction: the exertion of a pulling force that is applied to a fractured bone or dislocated joint to maintain proper position and facilitate healing

o splinting: an appliance (a type of orthotic) made of bone, wood, metal or plaster used for the fixation,

union, or protection of an injured part of the body

o casting: immobilization of a limb or body part with a stiff, solid dressing during the healing process

• cortisone injection: injections that can help relieve pain and inflammation in a specific area of the body. They are most commonly injected into joints, such as the ankle, elbow, hip, knee, shoulder, spine or wrist

• epidural injection: provides temporary or lasting relief from pain or inflammation in the spine or extremities

• extracorporeal shock wave therapy (ESWT): a procedure that uses low-dose sound waves applied to targeted areas to reduce pain and stimulate the damaged tissue cells to rebuild

• joint distention: the injection of sterile water into a joint capsule to help stretch the tissue and make it easier to move the joint

• joint manipulation: a provider moves a joint in different directions to help loosen tightened tissue

• platelet rich plasma (PRP) treatment: an injection of blood plasma containing a high concentration of platelets into damaged tissue to help promote healing

• TENS (transcutaneous electrical nerve stimulation) unit: a therapy that uses low voltage electrical current to provide pain relief.

• trigger point injection: a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin.

• viscosupplementation: a procedure in which a thick fluid called hyaluronate is injected into the knee joint

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Surgical Treatments The goal in performing surgery for musculoskeletal disorders is to improve, manage or treat symptoms and provide support and stability to the musculoskeletal system. Commonly performed procedures include:

• amputation: partial or complete removal or a limb or digit

• arthrocentesis: surgical procedure to remove an accumulation of fluid in a joint by using a needle or trocar inserted into the joint space

• arthrodesis: surgical procedure to fuse the bones in a degenerated, unstable joint

• arthroplasty: the surgical reconstruction or replacement of a joint.

• arthroscopy: visual examination of a joint, especially the knee, used primarily to detect trauma or lesions and to obtain a biopsy of synovial tissue for microscopic examination

• bone graft: surgical procedure that uses whole bone or bone chips to repair fractures with extensive bone loss or defects due to bone cancer.

o Bone taken from the patient's own body is known as an autograft. o Frozen or freeze-dried bone taken from a cadaver is known as an allograft.

• bunionectomy: surgical procedure to remove the prominent part of a metatarsal bone that is causing the bunion

• bursectomy: surgical excision of a bursa

• cartilage transplantation: surgical procedure that is an alternative to a total knee replacement; used to treat middle-aged adults with degenerative joint disease of the knee who have an active lifestyle

• discectomy: surgical removal of the whole or a part of an intervertebral disc

• external fixation: surgical procedure used to treat a complicated fracture. An external fixator orthopedic device has metal pins that are inserted in the bone on either side of the fracture and connected to a metal frame. This immobilizes the fracture. To lengthen a congenitally short leg, the device has screws that are turned each day to pull the bone and lengthen it.

• joint replacement surgery: surgical procedure to replace a joint that has been destroyed by inflammation. A prosthesis is inserted in its place.

o a prosthesis is a metal or plastic device that takes the place of of the bones in a joint

• ORIF (open reduction, internal fixation): treatment of bone fractures by the use of surgery to place the bones in proper position (reducing the fragments)

• osteotomy: the surgical cutting of a bone, to allow for re-alignment

• laminectomy: excision of the posterior arch of a vertebra; most often performed to relieve the symptoms of a ruptured intervertebral (slipped) disc

• selective dorsal rhizotomy: a neurosurgical procedure that selectively destroys problematic nerve roots in the spinal cord

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• spinal fusion: a surgical procedure used to permanently connect two or more vertebrae in the spine, eliminating motion between them

o anterior cervical discectomy and fusion (ACDF): surgery to remove a herniated or degenerative disc in the neck.

o anterior lumbar interbody fusion (ALIF): a type of spinal fusion that utilizes an anterior (front – through the abdominal region) approach to fuse the lumbar spine bones together.\

o transforaminal lumbar interbody fusion (TLIF): a spinal fusion procedure that fuses the front and back section of the spine through a posterior approach

• synovectomy: surgical excision of a synovial membrane Orthopedic Surgery Instruments Orthopedic surgery is not unlike carpentry. The surgical instruments commonly used are hammers, nails, screws, metal plates, chisels, mallets, gouges and saws.

• An osteotome is used to cut bone.

• A rongeur is a forceps that is used to remove small bone fragments.

Medical Specialty Knowledge - Orthopedics

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