Student Guide to Common Orthopedic Injuries

INTRODUCTION ...................................................................................................................... 4

SHOULDER ............................................................................................................................... 5

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

Glenohumeral (GH) Dislocation ................................................................................................. 6

Impingement, Tendinopathy, and Rotator Cuff (RC) Tear .............................................................. 6

Labral Tear .............................................................................................................................. 7

Biceps Tendinopathy ................................................................................................................. 7

Acromioclavicular (AC) Separation ............................................................................................ 8

Acromioclavicular (AC) Degenerative Joint Disease: .................................................................... 8

Adhesive Capsulitis (Frozen Shoulder) ........................................................................................ 8

Shoulder Special Tests Glossary ................................................................................................. 9

ELBOW ....................................................................................................................................12

Lateral Epicondylitis (Tennis Elbow) .........................................................................................13

Medial Epicondylitis (Golfer’s Elbow) .......................................................................................13

Olecranon Bursitis ...................................................................................................................13

Ulnar Collateral Ligament (UCL) Tear .......................................................................................14

Ulnar Nerve Entrapment ...........................................................................................................14

Biceps Tendon Rupture ............................................................................................................14

Posterior Elbow Dislocation ......................................................................................................15

Brief Notes on Elbow Fractures: ................................................................................................15

WRIST/HAND ..........................................................................................................................16

Scaphoid Fracture ....................................................................................................................16

Distal Radius Fracture ..............................................................................................................17

Triangular Fibrocartilage Complex (TFCC) Tear/Sprain ...............................................................17

Carpal Tunnel Syndrome ..........................................................................................................18

De Quervain’s Tenosynovitis ....................................................................................................18

Carpometacarpal Osteoarthritis (CMC OA) .................................................................................18

Thumb Ulnar Collateral Ligament (UCL) Sprain/Tear ..................................................................19

Trigger Finger (Stenosing Flexor Tenosynovitis) .........................................................................19

Mallet Finger ...........................................................................................................................20

Dorsal PIP Dislocation .............................................................................................................20

Hand/Wrist Special Test Glossary ..............................................................................................21

HIP ...........................................................................................................................................22

Hip Osteoarthritis .....................................................................................................................22

Femoral Fractures ....................................................................................................................22

Femoral Neck Fracture (Intracapsular) ........................................................................................22

Intertrochanteric Fracture (Extracapsular) ...................................................................................23

Avascular Necrosis (AVN or Osteonecrosis) of Femoral Head ......................................................23

Greater Trochanteric Pain Syndrome ..........................................................................................24

Femoroacetabular Impingement (FAI) ........................................................................................24

Hip Flexor Strain .....................................................................................................................25

Internal Snapping Hip Syndrome (Iliopsoas Tendonopathy) (Internal Coxa Saltans) ........................25

KNEE .......................................................................................................................................27

Osteoarthritis ...........................................................................................................................27

Anterior Cruciate Ligament (ACL) Tear .....................................................................................27

Medial Collateral Ligament (MCL) Tear .....................................................................................28

Posterior Cruciate Ligament (PCL) Tear .....................................................................................28

Lateral Collateral Ligament (LCL) Tear......................................................................................28

Meniscal Tear ..........................................................................................................................29

Patellar Dislocation ..................................................................................................................29

Patellofemoral Pain Syndrome ...................................................................................................29

Iliotibial Band (ITB) Syndrome .................................................................................................30

Patellar Tendinopathy (Jumper’s Knee) ......................................................................................30

Prepatellar Bursitis ...................................................................................................................31

Popliteal (Baker’s) Cyst ............................................................................................................31

Knee Special Test Glossary: ......................................................................................................32

ANKLE ...................................................................................................................................................... 33

Ankle Sprains .......................................................................................................................................... 33

Lateral Sprain ...................................................................................................................................... 33

Medial Sprain ...................................................................................................................................... 33

High Ankle Sprain (Syndesmotic) ...................................................................................................... 33

Osteochondral Defect (aka Osteochondritis Dessicans) ......................................................................... 34

Distal Fibular Fracture ............................................................................................................................ 34

Posterior Tibial Tendinopathy ................................................................................................................ 34

Peroneal Tendinopathy ........................................................................................................................... 35

Ankle Special Test Glossary ................................................................................................................... 37

FOOT ......................................................................................................................................................... 38

Hallux Rigidus ........................................................................................................................................ 38

Hallux Valgus (Bunion) .......................................................................................................................... 38

Jones Fracture ......................................................................................................................................... 38

Lis-Franc Injury ...................................................................................................................................... 39

Stress Fractures ....................................................................................................................................... 39

Midfoot Arthritis ..................................................................................................................................... 40

Morton’s Neuroma .................................................................................................................................. 40

BACK/SPINE ............................................................................................................................41

This study guide is designed to help students to begin formulating differentials for

musculoskeletal pain and injuries while learning the musculoskeletal exam. It is in no way meant

to be extensive, and presents only the most common and straightforward presentations for the

injuries covered.

First-year and second-year students should focus on the history and physical sections of each

injury. The imaging and treatment sections are included primarily to serve as a reference.

INTRODUCTION

Basic Ortho Principles to keep in mind…

1. Inspect first

. Is patient guarding the limb?

. Is there asymmetry, muscle atrophy, or bony deformity?

2. Neurovascular exam

. Assess sensation, motor strength, pulses, and capillary refill, particularly in the

setting of trauma

. Remember the 6 Ps of compartment syndrome: paresthesia, paralysis, pain, pallor,

poikilothermic (cold), pulseless.

3. Examine the joint above and the joint below

. E.g., if shoulder hurts, assess neck and elbow as well as shoulder.

. Knee: assess hip and ankle.

Basic terminology:

Dislocation: Injury to the joint that forces one or more bones out of position. To describe the type

of dislocation, refer to the position of the distal bone. E.g., posterior elbow dislocation means

ulna has moved posteriorly in relation to humerus.

Bursa: Small jelly-like sac containing synovial fluid that lies between bone and soft tissue and

provides cushioning or lubrication. Bursitis, an inflamed swollen bursa, may develop due to

overuse of friction. (E.g., a person who cleans for a living kneeling on a wood floor may develop

pre-patellar bursitis.)

Tendonitis: A type of tendinopathy where there is inflammation of a tendon.

Paresthesia: Tingling, pricking, tickling, or burning sensation of a person’s skin with no chronic

physical effect. “Pins & needles” (e.g., foot falling asleep).

SHOULDER

Things to remember for shoulder pain evaluation:

1. Rule out referred pain (cardiac, diaphragm, gallbladder, spleen).

2. Evaluate the joint above and below (neck/elbow).

3. Perform neck, neurologic, and vascular exams.

4. Evaluate scapulothoracic movement for asymmetry, which may contribute to shoulder

pain.

Note: If history of trauma, x-ray to rule out fracture. Shoulder fractures otherwise not covered

here.

Shoulder Anatomy

3 bones:

Clavicle

Scapula (acromion, coracoid process, glenoid fossa)

Humeral head

Glenohumeral joint is stabilized by static and dynamic stabilizers. Static stabilizers include

the labrum—a fibrocartilaginous cup that deepens the socket (glenoid fossa), glenohumeral

ligaments (superior, middle and inferior), coracohumeral ligament, and biceps tendon. Dynamic

stabilizers include the 4 rotator cuff muscles: supraspinatus, infraspinatus, subscapularis, and

teres minor.

Glenohumeral (GH) Dislocation

Anterior dislocation is much more common than posterior dislocation.

History: Often due to fall or trauma with the arm abducted and externally rotated. Patient may

also have chronic shoulder instability with frequent dislocations bilaterally.

Physical exam: Inspect for deformity, arm externally rotated. Positive apprehension test is

suggestive of shoulder instability.

Imaging: Plain radiographs including A/P view, Y view, and axillary view. Evaluate for

associated injuries such as fractures.

Treatment: If unilateral and secondary to trauma, patient may require surgery to prevent

recurrence. If atraumatic and bilateral instability, start with physical therapy for patient.

Complications: Axillary nerve injury, instability and repeat dislocations, cortical depression of

humeral head (Hill Sachs lesion), labral disruption and bony avulsion (Bankart lesion).

Posterior dislocation is uncommon and usually associated with electric shock, seizure, or high

velocity trauma. Physical exam may show obvious deformity with lack of external rotation.

Treatment is immediate reduction and immobilization.

Impingement, Tendinopathy, and Rotator Cuff (RC) Tear

Shoulder impingement is compression of

structures between the acromion and

glenohumeral joint. Rotator cuff tendons,

subacromial bursa, labrum and/or biceps tendon

are the most commonly affected structures.

Risk factors include GH instability, repetitive

overhead activity, and age.

History: Insidious onset, increased pain with overhead activity, night pain, and pain radiating to

deltoid.

Physical exam:

➢ Impingement: Full active and passive range of motion (although may be limited by pain).

● positive Hawkins-Kennedy (pain with passive flexion and internal rotation)

● positive Neer (passive arc),

● active painful arc (>90 degrees)

➢ RC tear: Full passive but decreased active range of motion. Most commonly torn muscle

is supraspinatus due to direct pressure from acromion.

● supraspinatus: empty can test, isometric abduction

● infraspinatus: external rotation

● subscapularis: lift off, internal rotation

Imaging: Ultrasound. MRI if concern for RC tear.

Treatment: Limit flexion of GH joint to <90 degrees. Physical therapy to increase rotator cuff

strength. NSAIDs. Refer to ortho for RC tear.

Labral Tear

The glenoid labrum (glenoid ligament) is a

fibrocartilaginous cup that deepens the glenoid

fossa.

Labral tear is common in overhead athletes such

as gymnasts and swimmers, or after traumatic fall

or dislocation. Superior labral anterior to

posterior (SLAP) most common and is often

associated with proximal biceps tear.

History: Deep, poorly localized shoulder pain and

instability, “catching” sensation with movement

Physical exam: Pain with compression of GH

joint and pronation.

Imaging: MRI

Treatement: NSAIDs. Physical therapy to improve strength and range of motion. Surgery if pain

does not improve with non-surgical management.

Biceps Tendinopathy

Long head of biceps originates intra-articularly at the superior glenoid tubercle.

Biceps supinates and flexes the arm at the elbow.

Biceps tendinopathy is most commonly secondary to shoulder impingement or shoulder

instability. Risk factors include repetitive pulling, lifting, reaching, or throwing.

History: Anterior shoulder pain that may radiate to the bicep. Worse with flexion and supination.

If tendon rupture, patient may hear a “pop” followed by weakness or swelling.

Physical exam: Bicipital groove tender to palpation. Positive Speed’s test.

If tendon rupture present, then popeye deformity (enlarged distal biceps muscle) and weakness

Imaging: Ultrasound to evaluate for tendinopathy. MRI for severe injuries.

Treatment: Rest, ice, NSAIDs, glucocorticoid injection.

Ortho referral if patient is an athlete, or work requires arm strength, particularly for biceps

tendon rupture.

Acromioclavicular (AC) Separation

Injury to the AC joint ranges from mild sprain of AC

ligaments to severe disruption of AC ligaments,

coracoclavicular ligaments, and muscular attachments and

displacement of the clavicle.

History: Common in contact sports after falling onto the

superior or lateral aspect of the shoulder.

Physical exam: AC joint tenderness. Pain with passive

adduction across the chest (AC compression).

Imaging: Radiograph- AP view, arm internally rotated with

comparison view of unaffected side.

Treatment: depends on the severity of the injury.

Involvement of AC ligaments only or partial CC ligament is

treated conservatively with rest, ice, sling followed by rehab.

Orthopedic consult for more severe injuries.

Acromioclavicular (AC) Degenerative Joint Disease:

History: Often asymptomatic. If symptomatic, typically presents with pain over deltoid,

trapezius, AC joint. Worsens with overhead or cross body movement (adduction)

Physical: AC joint tender to palpation and enlarged. Pain with passive adduction (scarf test).

Imaging: Plain radiographs to assess for changes consistent with osteoarthritis

Treatment: conservative (activity modification, ice, nsaids). Consider referral to orthopedics if no

improvement.

Adhesive Capsulitis (Frozen Shoulder)

Stiffness thought to be caused by adhesions and fibrosis of synovial lining with thickening and

contraction of GH joint capsule leading to reduced joint volume. Although the condition is

painful, the decreased range of motion is mechanical, not secondary to pain.

Risk factors include diabetes, autoimmune conditions and prior shoulder injuries—basically,

things that predispose to inflammation.

History: insidious onset of shoulder pain and stiffness, may be worse at night. Stiffness may limit

daily activities (unable to put on a coat, etc.)

Physical exam: limited active and passive range of motion.

Imaging: radiograph to rule out osteoarthritis.

Treatment: Condition is usually self-limited, but may persist for years. Conservative therapy with

analgesics, gentle range of motion exercises, glucocorticoid injections if no improvement. Refer

to orthopedics after 10-12 months if no improvement.

Back to Table of Contents

Shoulder Special Tests Glossary

Apprehension test: Patient lying supine with arm off table. Elbow flexed to 90 degrees and

shoulder abducted to 90 degrees. Apply gentle force of external rotation to the arm. Positive test

is apprehension of the patient, not pain. (They may ask you to stop for fear of dislocation)

Back to Shoulder Dislocation

Hawkins-Kennedy: Passive flexion of elbow and shoulder to 90 degrees (in neutral position).

Examiner applies force of internal rotation to shoulder. Pain= positive suggesting supraspinatus

impingement.

Back to Impingement/RC Tear

Neer test: stabilize patient’s scapula. Pronate (internally rotate) the patient’s arm and forward

flex as far as possible up to 180 degrees. Pain = positive. Back to impingement/RC Tear

Empty can: Have patient raise straight arms to 30-45 degrees with internal rotation (thumbs

pointing downward) and apply downward pressure. Weakness is suggestive of RC tear. Back to

impingement/RC Tear

Lift off: arm internally rotated with dorsum of hand against the back. Ask patient to push

posteriorly against resistance. Weakness indicates subscapularis injury.

Back to impingement/RC Tear

Speeds test: Elbow straight, arm supinated and flexed to 90 degrees at the shoulder, pain in the

bicipital groove with resistance to downward pressure)

Back to Biceps Tendinopathy

Scarf test: Elbow flexed to 90 degrees and adduct the patients arm, placing the patient’s hand on

his/her opposite shoulder.

Back to AC Degenerative Joint Disease

ELBOW

Anatomy Review:

Medial epicondyle is the origin of wrist flexors.

Lateral epicondyle is the origin of wrist extensors.

Ulnohumeral joint flexes and extends.

Radiohumeral joint supinates and pronates.

Lateral Epicondylitis (Tennis Elbow)

Recall that wrist extensors originate at the lateral epicondyle and wrist flexors originate at the

medial epicondyle.

Lateral epicondylitis is most often a tendinopathy of the extensor carpi radialis brevis at the

lateral epicondyle.

History: patient complains of localized pain at the lateral epicondyle with extension of the wrist.

Physical exam: point tenderness at lateral epicondyle. Pain with resisted wrist extension. Full

active and passive range of motion at the elbow. Note: effusion should not be present, as

epicondylitis is an extraarticular process.

Imaging: usually not indicated

Treatment: Activity modification to limit repetitive motion. Physical therapy. Modifying athletic

techniques. NSAIDs. Counterforce bracing. Consider referral if no improvement with 6 months

of non-operative management.

Medial Epicondylitis (Golfer’s Elbow)

Less common than lateral epicondylitis. Tendinopathy of pronator teres and flexor carpi

radialis at the medial epicondyle.

History: pain with wrist flexion and supination.

Physical exam: Medial epicondylar point tenderness to palpation. Pain resisted pronation of the

forearm and resisted wrist flexion.

Treatment: Activity modification to limit repetitive motion. Physical therapy. Modifying athletic

techniques. NSAIDs. Counterforce bracing. Consider referral if no improvement with 6 monthf

non-operative management.

Olecranon Bursitis

Swelling of the olecranon bursa.

Acute: due to trauma or infection

Insidious: due to chronic irritation

History: Patient complains of swelling and pain

over olecranon with pressure.

Physical exam: Effusion over olecranon,

tenderness over olecranon, full active and passive

ROM

Caution: if there is inflammation (redness, heat, swelling) and decreased range of motion, then

you should be concerned about synovitis (inside the joint, as opposed to the bursa) which

requires fluid aspiration and analysis.

Imaging: Not required. Ultrasound if concern for synovitis.

Treatment: If traumatic, compression with elbow pad, ice for

swelling, NSAIDs for pain. Antibiotics for infection.

Ulnar Collateral Ligament (UCL) Tear

Common in throwers, wrestlers, gymnasts and football players.

History of valgus stress on outstretched arm.

Physical exam: Valgus stress w/ 30 degrees flexion→ pain and

instability

Imaging: MRI with contrast arthrography

Treatment: Conservative: ice and NSAIDs. Activity modification

(e.g. no throwing) for approximately 6 months. Surgery:

Reconstruction of UCL (Tommy John surgery)

Ulnar Nerve Entrapment

History: Paresthesias of the ulnar 1½ digits and ulnar dorsal hand.

Physical exam: Symptoms reproduced with tapping (tinel sign),

cubital tunnel compression and/or elbow hyperflexion. Weakness

of fingers and interosseus muscle atrophy may be appreciated in

late stages.

Check for ulnar nerve subluxation with flexion/extension.

Caution: Perform neck exam to rule out C8 pathology. Ulnar nerve entrapment may also

accompany UCL strain/tear, so be sure to test for valgus instability and pain with valgus stress.

Treatment: activity modification, night splint (relative elbow extension), NSAIDs. Surgery for

refractory cases.

Biceps Tendon Rupture

Rupture of distal biceps tendon which attaches to radial tubercle.

History: Forceful lifting or supination followed by sudden pain deep in the antecubital fossa.

Physical exam: Tenderness to palpation of radial tubercle and antecubital fossa. Pain/weakness

with flexion/supination.

Imaging: Ultrasound.

Treatment: Surgical reattachment of tendon.

Posterior Elbow Dislocation

History: Fall/twisting injury to elbow.

Physical exam: Olecranon prominent posteriorly.

Imaging: Radiograph to rule out associated fracture

Treatment: Stabilize the arm. Reduction should only be performed

by experienced practitioner. Immobilization <3 wks. F/u with

physical therapy.

Complications: ulnar n. injury > median n. injury, brachial a. injury

is rare. Perform careful neurovascular exam.

Brief Notes on Elbow Fractures:

Radial Head/Neck fracture: Commonly occurs after fall. May be occult (posterior fat pad sign on

radiograph). Causes elbow stiffness if not mobilized quickly.

Olecranon fracture: Common in elderly patient after fall

Medial epicondyle avulsion fracture: Throwing injury common among pediatric patients. (May

endorse “popping sensation” at time of injury.)

Back to Table of Contents

WRIST/HAND

Scaphoid Fracture

History: Radial wrist pain after forward

fall onto outstretched pronated hand.

Physical exam: Snuffbox tenderness

indicates scaphoid fracture until proven

otherwise! (see picture) Swelling,

decreased range of motion, or pain with

resisted supination may be present.

Imaging: Plain radiographs including

lateral, oblique, and scaphoid views. Up

to 30% of the radiographs may be non-

diagnostic.

Treatment:

Immobilize hand/wrist and repeat films in 2 weeks if radiographs are non-diagnostic.

If radiograph shows fracture, then thumb spica cast for 6-10 weeks.

Refer to surgeon if scaphoid is displaced > 1 mm.

Distal Radius Fracture

History: Athletic injuries in young people. If -> 50 years old, then could have fallen onto

outstretched hand.

Physical exam: Tenderness to palpation of distal radius. Swelling. Deformity indicates

displacement. Palpate for ulnar tenderness and snuffbox tenderness as well.

Caution: Acute carpal tunnel syndrome (acutely worsening median nerve dysfunction) on exam

indicates that compartment syndrome is developing and is a surgical emergency!

Imaging: Plain radiographs including lateral and oblique.

Treatment: Reduction and cast immobilization if there is minor displacement.

Refer to surgeon if open fracture, neuro or vascular complications, unstable fracture (e.g.,

fracture with dislocation).

Triangular Fibrocartilage Complex (TFCC) Tear/Sprain

TFCC: Triangular fibrocartilage discus + radioulnar

ligaments (stabilizes distal radial and ulnar joints) +

ulnocarpal ligament

History: Patient fell onto outstretched hand and twisted

wrist. Ulnar sided wrist pain.

Physical exam: Ulnar-sided pain with forced ulnar deviation,

wrist extension, and resisted pronation or supination.

Imaging: Plain radiographs to rule out ulnar styloid fracture

and ulnar variance. MRI and arthrography if tear is

suspected.

Treatment:

TFCC sprain: Splint for 4 weeks with ice and NSAIDs. Consider ortho referral if no

improvement.

TFCC tear: Refer to ortho.

Carpal Tunnel Syndrome

The carpal tunnel contains the median nerve,

flexor pollicis longus tendon, flexor digitorum

superficialis, flexor digitorum profundus.

Increased pressure in carpal tunnel can cause

nerve damage.

History: Patient feels numbness or

parasthesias on volar surface of radial 3.5

fingers.

Physical exam: May have positive Tinel and

Phalen signs. If in later stage, patient will have

decreased sensation of light touch and

vibration, pain and temp are preserved longer.

Treatment: Activity modification, night

splinting, NSAIDs. Consider corticosteroid

injection for short-term relief.

Surgical referral if chronic problem and no

relief with multiple corticosteroid injections.

De Quervain’s Tenosynovitis

Tendon entrapment of abductor pollicis longus and extensor pollicis brevis under radial styloid.

May present similarly to carpometacarpal osteoarthritis.

History: Overuse injury caused by gripping. Pain in radial volar aspect of wrist with pinching or

use of the wrist. Pain with extension/abduction of thumb.

Physical exam: Pain with resisted thumb abduction and extension. Positive Finklestein

maneuver.

Imaging: Radiograph to rule out other etiology (e.g., OA), but not necessary for diagnosis.

Treatment: Ice and NSAIDs. Use thumb spica splint to restrict movement (particularly thumb

abduction and extension). Perform stretching exercises. Glucocorticoid injections if needed.

Refer to surgery if no improvement after 2 glucocorticoid injections and 1 year.

Carpometacarpal Osteoarthritis (CMC OA)

History: Insidious onset of pain in CMC. Patient exhibits pain with pinching or gripping and may

feel that the thumb is weak.

Physical exam: Palpate for tenderness on volar side of joint. Pain with axial compression and

movement of thumb. Crepitus. Decreased strength and range of motion.

Imaging: Plain radiographs, but not required for diagnosis

Treatment: Analgesic therapy (acetaminophen, NSAIDs, etc.), May give glucocorticoid

injections, capsaicin, or a glucosamine supplement. Definitive treatment is surgery.

Thumb Ulnar Collateral Ligament (UCL) Sprain/Tear

(Gamekeeper’s Thumb or Skier’s Thumb)

History: Hyperabduction or hyperextension of thumb. E.g., hit thumb on ski pole at high

velocity.

Physical exam: Palpate for tenderness over thenar eminence. Look for swelling or thumb

displacement. May exhibit ligamentous laxity with valgus stress at thumb MCP.

Imaging: Plain radiographs to rule out bony avulsion.

Treatment: Casting.

Complication: Stener lesion—the aponeurosis of adductor pollicis goes between UCL and its

insertion site, preventing healing. Requires surgical repair.

Trigger Finger (Stenosing Flexor Tenosynovitis)

Inflammation causes thickening flexor tendon which is then unable to glide smoothly through the

retinacular pulley system.

History: Patient complains of snapping and pain with

flexion of affected finger, may “lock” in a flexed position.

Physical exam: Tenderness of MCP joint on volar side of

hand, directly over affected tendon. Look for pain with

resisted flexion or passive extension.

Imaging: None indicated.

Treatment: Immobilize affected finger(s) with buddy taping

or finger splint for 4-6 weeks. Ice as needed for pain. Give

glucocorticoid injections for severe cases.

Surgery: Refer to surgeon after failure of 2 glucocorticoid injections and perform trigger finger

release.

Mallet Finger

Extensor tendon injury of DIP.

History: Direct axial blow to fingertip (e.g,

basketball, or a hard surface). Pain over dorsal DIP

with inability to straighten finger.

Physical exam: Swelling and ecchymosis (if acute).

Flexion of DIP at rest. Dorsal DIP tender to

palpation. Limited active extension of affected

finger. Usually full passive range of motion.

Imaging: Plain radiographs including A/P, lateral,

and oblique to evaluate for fracture and/or

misalignment of finger.

Treatment: If no subluxation, splint DIP joint in extension for 6-8 weeks

Refer to ortho if complicated (e.g., limited passive range of motion, subluxation, or full

laceration of tendon.

Dorsal PIP Dislocation

History: Hyperextension of finger, acute onset pain, and inability to move finger.

Physical Exam: Swelling and deformity present on inspection. Impaired active and passive range

of motion.

Imaging: Plain radiographs including A/P, true lateral, and oblique to rule out fracture. Repeat

radiographs after reduction.

Treatment: Reduce if simple dislocation (single joint, no fracture, non-open joint with intact

neurovascular function). Splint for 3-5 days with buddy tape to adjacent finger. Perform range of

motion exercises. Consult orthopedics if complicated.

Back to Table of Contents

Hand/Wrist Special Test Glossary

Tinel: Tapping lightly over volar aspect of wrist reproduces paresthesias.

Return to Carpal Tunnel Syndrome

Phalen maneuver: placing dorsum of hands together for 30 sec-1min reproduces paresthesias via

compression of carpal tunnel.

Return to Carpal Tunnel Syndrome

Finkelstein maneuver: Pain over radial styloid with passive ulnar deviation of fist with thumb

adducted inside the fist. (Maximally stretching the affected tendons)

Return to De Quervain Tenosynovitis

Return to Table of Contents

HIP

Hip Osteoarthritis

History: Chronic anterior hip/groin pain,

worse with movement and weight bearing

Physical exam: Pain with limited flexion

and internal rotation.

DDx: Occult frx, osteonecrosis.

Imaging: 1. plain radiograph. 2. MRI if

diagnosis is unclear.

Treatment: NSAIDs, activity modification.

Definitive treatment is surgery.

Femoral Fractures

Intracapsular fracture predisposes to avascular necrosis due to poor blood supply.

Femoral Neck Fracture (Intracapsular)

High risk AVN.

History: Fall onto lateral hip, twisting mechanism with foot

planted (elderly). High intensity trauma, such as car

accidents in young people. Acute onset of pain with

movement, pain associated with weight bearing.

Physical exam: If displaced, leg may be externally rotated

and shortened. Swelling and ecchymosis may be absent.

Imaging: Radiographs including AP view with maximum

internal rotation and lateral view. If high suspicion, keep

patient non-weight bearing until MRI is obtained.

Treatment: refer to orthopedic surgeon.

Intertrochanteric Fracture (Extracapsular)

High risk of displacement. Low risk of AVN.

History: Pain after fall in elderly person.

Physical exam: Swelling and ecchymosis often present. Leg may be shortened and externally

rotated (if displaced). Local tenderness to palpation.

Caution: Risk of blood loss into thigh because fracture is extracapsular. Monitor for

hemodynamic stability.

Imaging: See above.

Treatment: Consult orthopedics. Usually requires surgical fixation.

Avascular Necrosis (AVN or Osteonecrosis) of Femoral Head

Necrosis of bone trabeculae and marrow that may result in collapse of bone. Thought to be

secondary to impaired bone vasculature, although etiology is often unclear.

Risk factors: high EtOH intake, high dose or long term corticosteroids, and trauma

mean age <40 y/o

History: Groin pain with movement and weight bearing. ⅔ of patients have pain at rest, and ⅓

have pain at night. +/- thigh or buttock pain.

Physical exam: Similar to osteoarthritis. Non-specific. Pain with flexion and internal rotation

Imaging: AP and frog leg lateral radiograph (not sensitive for early AVN). MRI is the gold

standard.

Treatment: Treatment is controversial. Goal is to preserve native joint. Treatment options vary

depending on symptoms and extent of disease.

1. non-operative: includes bisphosphonates, vasodilators, anticoagulants and statins.

2. joint-preserving surgery

3. total hip replacement

Greater Trochanteric Pain Syndrome

(Trochanteric Bursitis, IT Band Syndrome, Gluteus Medius Tendinopathy)

Greater trochanter is insertion point for gluteus medius & minimus, piriformis, superior

gemellus, obturator externus and obturator internus.

Greater trochanteric pain syndrome refers to lateral hip pain caused by gluteus medius or

minimus tendinopathy, IT band syndrome (+/- snapping hip), piriformis tendinopathy, or

trochanteric bursitis.

History: Lateral hip pain over greater trochanter, worse with pressure (lying on the affected side)

and with standing on affected leg.

Physical exam: Tenderness to palpation of greater trochanter. Pain with resisted abduction and

external rotation. Trendelenburg sign may be present if gluteus medius tear exists but otherwise,

full active and passive ROM and full strength.

Imaging: MRI = gold standard. Ultrasound can assess tendons and bursae.

Treatment: rest, ice, NSAIDs. Steroid injection or lidocaine. Physical therapy and activity

modification. Surgery only for refractory cases.

Femoroacetabular Impingement (FAI)

Damage to acetabulum and femoral neck due to abnormal contact between the two structures.

Most common in young adults. Predisposes to early hip arthritis.

2 types of impingement, often seen in combination:

Cam impingement: abnormal femoral head-neck contour (femoral neck is wide)

Pincer impingement: (overcoverage) acetabulum is too deep

History: insidious onset hip/groin pain, similar to OA but in young adults.

Physical exam: Pain with passive flexion, adduction, and internal rotation at the hip.

Imaging: Plain radiographs. MRI (hip series) and MR arthrography (allows for evaluation of

labrum and acetabular rim).

Treatment: Surgery aims to recreate normal anatomy, increase range of motion, and decrease

femoral abutment of acetabular rim.

Hip Flexor Strain

Stretching or tearing of 1 or more of the hip flexor

muscles. Commonly seen in runners, football

kickers, & soccer players.

History: sharp or pulling pain in anterior hip/groin.

Often occurs during sprinting or forceful kicking, and

pain with walking up stairs.

Physical exam: Anterior groin TTP. Pain with hip

flexion against resistance.

Imaging: Radiograph to rule out avulsion fracture.

U/S or MRI to evaluate severity of strain.

Treatment: RICE, NSAIDs, PT.

Internal Snapping Hip Syndrome (Iliopsoas

Tendonopathy) (Internal Coxa Saltans)

Transient subluxation of iliopsoas tendon over pelvic

brim or anterior aspect of femoral head. May be

associated with iliopsoas tendinitis.

Common in athletes with extreme hip ROM

(e.g., ballerinas).

History: Painful snapping with hip extension from flexion, e.g., pain with running, standing up

from seated position.

Physical exam: audible popping with pain anteriorly during hip extension and internal rotation

from a flexed and externally rotated position.

Imaging: Dynamic ultrasound and/or MRI.

Treatment: Activity modification, NSAIDs, stretching. Surgical lengthening or release is

indicated for refractory cases.

Caution: Intraarticular DDx includes labral tear, cartilage defects, loose bodies, fracture

fragments. Intraarticular pain often described as “catching” or “sharp/stabbing.”

Note: Pelvic fractures are not covered, but in case of trauma (e.g., high fall or car crash), suspicion for

pelvic fracture must be high as it can lead to hemodynamic instability and death.

Back to Table of Contents

KNEE

Osteoarthritis

Degeneration of articular cartilage.

3 compartments: medial, patellofemoral, lateral.

Risks: >50 y/o, obesity.

History: Chronic aching pain, insidious onset, worse with weight bearing.

Physical exam: crepitus, bony tenderness and enlargement. No warmth. +/- small effusion.

Imaging: Plain weight-bearing radiographs, include sunrise view (patellofemoral compartment)

Treatment: Analgesics, rest, PT. Long term: total knee replacement surgery.

Anterior Cruciate Ligament (ACL) Tear

History: Non-contact pivoting injury, may have heard an audible pop.

Physical exam: Positive Lachman test, Anterior drawer test. Swelling from hemarthrosis is

common.

Imaging: Plain radiograph followed by MRI

Treatment: PT – mobilization; do not immobilize. Surgical repair.

Note: Associated meniscal tear is common.

Medial Collateral Ligament (MCL) Tear

History: Valgus force to knee (e.g., direct blow from outside).

Physical exam: Pain and instability with valgus stress at 30 degrees flexion.

Imaging: MRI.

Treatment: hinged knee brace.

Posterior Cruciate Ligament (PCL) Tear

History: Blow to anterior tibia w/ flexed knee (dashboard injury), fall onto ground w/

plantarflexed foot.

Physical exam: Posterior drawer.

Imaging: Plain radiographs to eval for avulsion injury, stress radiographs, MRI.

Treatment: Depends on degree of injury. Some may be managed non-operatively w/ rehab

focused on knee extensor strengthening. PCL surgical reconstruction if combined injury or

complete tear with instability.

Lateral Collateral Ligament (LCL) Tear

LCL is weakest of knee ligaments, but injury is uncommon due to mechanism.

History: Varus stress followed by pain.

Physical exam: Lateral joint line ttp. Pain and instability with varus stress at 30 degrees flexion.

Imaging: Consider AP, lateral, varus stress radiographs. May consider MRI if question of

additional injury.

Treatment: Rehab/brace.

Meniscal Tear

History:

Young patients: twisted knee while

flexed with foot planted on the

ground. +/- popping sound.

Older patients: degenerative tear,

may not have h/o trauma.

Stiffness. Sensation of knee

catching/locking. Pain exacerbated by

twisting. May perceive inappropriate knee

position or that knee isn’t moving

properly.

Physical exam: Depending on type of tear,

exam may be normal. Effusion common.

Medial or lateral joint line tenderness to

palpation. Positive McMurray test.

Abnormal range of motion with inability to

fully extend knee.

Imaging: Radiographs- sunrise, tunnel, PA,

lateral. MRI to characterize extent of tear if considering surgery.

Treatment: If no swelling, catching, locking or “giving way” then treat conservatively with PT to

strengthen quads and hamstrings, rest, ice and crutches.

Refer to orthopedic surgeon if large effusion, disabling symptoms or poor response to

conservative therapy.

Patellar Dislocation

Commonly a lateral displacement of patella from trochlear groove. May be confused with ACL

tear at presentation due to history of “loud pop” and immediate swelling.

History: Foot planted, internal rotation of knee with valgus force. Pt may endorse hearing loud

pop/tear, knee giving out, and severe pain.

Physical exam: limited range of motion due to swelling/hemarthrosis. Patella may be palpated

laterally. Medial edge of patella and medial femoral condyle tender to palpation.

Imaging: AP, lateral, sunrise view radiographs (evaluate after reduction)

Treatment: Reduction followed by RICE, NSAIDs, brace. Start rehab after 2-3 days to encourage

mobility.

Patellofemoral Pain Syndrome

Overuse injury leading to acute or chronic knee pain. May be due to sudden overload/increase in

activity, imbalance of quadricep muscles, or malalignment of patella in trochlear groove.

History: Pain under or around the patella, poorly localized. “Theatre sign” hurts when patient

stands up after sitting for long period. Worse with squatting, running, ascending or descending

stairs. Review exercise history (recent increase in intensity).

Physical exam: Positive patellofemoral compression test,

patella facet retinaculum tenderness.

Imaging: Not indicated unless concern for patellofemoral

instability or OA. PFPS is a clinical Dx.

Treatment: NSAIDs, ice, activity modification, PT-

quadriceps strengthening, rehab, orthotics, bracing.

Iliotibial Band (ITB) Syndrome

ITB anatomy: iliac crest to proximal tibia. Courses over

lateral femoral epicondyle, proximal to joint line.

Overuse injury, previously thought to be due to friction

between ITB and femoral epicondyle.

Exact etiology is unknown.

Common in runners

History: Sharp or burning lateral knee pain before/during

foot strike of running or during downward pedal force on

bike

Physical exam: ITB tender over lateral femoral tubercle.

Positive Noble test. Positive Ober’s test.

Imaging: none required. +/- ultrasound

Treatment: Rest, ice, NSAIDs followed by PT for strength and mobility, rehab

Patellar Tendinopathy (Jumper’s Knee)

History: Anterior knee pain. Worse with running, jumping, squatting.

Physical exam: Patellar tendon tender to palpation. May be enlarged compared to non-affected

side. Full knee range of motion.

Imaging: Ultrasound to assess for tendinopathy +/- partial tears.

Treatment: activity modification, PT, stretching, ice, NSAIDs (short term).

Prepatellar Bursitis

Bursa is located between patella and overlying skin

History:

2 mechanisms:

Direct blow or a fall onto the knee. Bleeding into

bursa causes inflammatory reaction-->bursitis.

Would likely see bruising.

Chronic use from people who work on their

knees (carpet layers & plumbers).

Physical exam: Effusion over the patella. Patella tender

to palpation. Pain at patella with knee flexion. If skin is

hot, red, or exquisitely tender, bursa may be infected.

Imaging; Radiograph if history concerning for patellar

fracture.

Treatment: -May aspirate fluid if hindering recovery and

analyze for infection. Antibiotics prn infection. Ice.

PT if limited ROM. Refractory cases may warrant surgery.

Popliteal (Baker’s) Cyst

Soft, painless cyst in the popliteal fossa (swelling of gastrocnemius-semimembranous bursa).

Usually an incidental finding (on imaging) secondary to either OA or meniscal tear which can

both cause synovial fluid to leak from the joint capsule, forming a cyst.

History: Usually painless. Patient may complain of swelling, stiffness, discomfort with standing

for long periods.

Physical exam: Often not appreciable on exam. If large cyst: swelling posteriorly. If cyst

dissects, lower leg may appear swollen, red, and tender (much like DVT!).

Imaging: Usually not indicated. Ultrasound to rule out solid mass, aneurysm, or DVT.

Treatment: Treat underlying joint disorder. If symptomatic, corticosteroid injections.

Back to Table of Contents

Knee Special Test Glossary:

Lachman’s test: Used to diagnose ACL injury. Patient supine with affected knee flexed at 20-30

degrees. Examiner places 1 hand behind tibia & other hand on patient’s thigh then pulls the tibia

forward to assess laxity. If significant laxity is demonstrated, this is a positive test. Return to

ACL Tear

Anterior drawer: Used to diagnose ACL injury. Patient supine with the affected knee bent at 90°

and foot flat on the table. Gently sit on the patient’s foot to prevent movement and grasp the

patient’s affected knee with your hands and pull the shin bone forward while assessing for laxity.

If significant laxity is demonstrated, this is a positive test. Repeat on the other knee for

comparison. Return to ACL Tear

Posterior drawer: Used to diagnose PCL injury. Patient supine with the affected knee bent at 90°

and foot flat on the table. Gently sit on the patient’s foot to prevent movement and grasp the

patient’s affected knee with your hands and push the shin bone posteriorly, assessing for laxity.

If significant laxity is demonstrated, this is a positive test. Repeat on the other knee for

comparison. Return to PCL Tear.

McMurray’s test: Used to diagnose meniscal tears. Patient supine. Start with knee maximally

flexed. Apply valgus force to the knee, while at the same time externally rotating and extending

the knee completely. Then place the affected leg back in the maximal hip and knee flexion.

While palpating the joint line, apply a varus force to the knee, while at the same time internally

rotating and extending the knee completely. Pain or clicking is a positive result.

Return to Meniscal Tear.

Patellofemoral compression test: pain when patella is pressed straight down into trochlear groove

with leg extended. Return to Patellofemoral Pain Syndrome

Patella facet retinaculum tenderness: With leg relaxed, displace patella laterally or medially and

palpate in facet and underside of patella to evaluate for tenderness.

Return to Patellofemoral Pain Syndrome

Noble’s test: With patient lying in lateral decubitus position, passively flex patient’s affected

limb’s hip and knee to 90 degrees. Apply pressure with your thumb over the IT Bank proximal to

the lateral femoral condyle. Have the patient actively extend his/her hip and knee. Pain before

30° short of knee extension is a positive sign. Return to ITB Syndrome

Ober’s test: With patient lying in lateral decubitus position on unaffected side, with bottom hip

and knees flexed to approximately 90 degrees for stability. Passively abduct and extend the hip

of the affected leg. Allow the leg to then adduct, still extended (lowering the table behind the

patient’s unaffected leg). Test is positive if the leg will not adduct past neutral position,

indicating tightness of ITB or tensor fasciae latae. Return to ITB Syndrome

Return to Table of Contents.

ANKLE

Ankle Sprains

Lateral Sprain

Most common (85%). Anterior talofibular

ligament (ATFL) is affected first.

History: Rolled ankle (inversion), may hear

popping noise at time of injury. Pain with

weight bearing.

Physical exam: Swelling distal to lateral

malleolus. If ATFL full tear, positive

Anterior drawer. If posterior talofibular

(TFL) tear, positive Talar tilt.

Imaging: AP, lateral, ankle mortise

radiographs indicated to evaluate for fracture

if Ottowa ankle criteria are met.

Treatment: Stabilize ankle with brace,

mobilize when tolerable, RICE, NSAIDs,

PT/rehab.

Refer to orthopedic surgeon if tendon rupture, fracture, dislocation or subluxation.

Medial Sprain

History: Medial pain after eversion of foot. Uncommon.

Physical exam: swelling distal to medial malleolus.

Imaging: AP, lateral, ankle mortise radiographs indicated to evaluate for fracture only if Ottowa

ankle criteria are met.

Treatment: Stabilize ankle with brace, mobilize when tolerable, RICE, NSAIDs, PT/rehab.

Refer to orthopedic surgeon if tendon rupture, fracture, dislocation or subluxation.

High Ankle Sprain (Syndesmotic)

Syndesmotic ligament connects tibia to fibula.

Sprain usually due to force of excessive external rotation on fibula. Common

in skiing/hockey (due to stiff boots) or high impact sports. Recover time is

twice as long as LCL sprains.

Physical exam: proximal ankle swelling. Pain with external rotation. Positive

squeeze test.

Imaging: AP, lateral, ankle mortise radiographs indicated to evaluate for

fracture if Ottowa ankle criteria are met.

Treatment: Stabilize ankle with brace, mobilize when tolerable, RICE,

NSAIDs, PT/rehab.

Refer to orthopedic surgeon if tendon rupture, syndesmotic injury (high

ankle sprain), fracture, dislocation or subluxation.

Osteochondral Defect (aka Osteochondritis Dessicans)

History: Patient experiences chronic worsening pain after inversion ankle injury (ankle sprain)

often with associated clicking, stiffness, and weakness.

Physical exam: Look for swelling with or without effusion. Palpate for tenderness over talar

dome while plantar-flexing and dorsi-flexing the ankle.

Imaging: Plain radiographs including oblique, mortise, and plantar-flexed views. Consider MRI

if symptoms persist and radiographs are normal.

Treatment: Rest, immobilization, NSAIDs, and physical therapy. Refer to orthopedics.

Distal Fibular Fracture

Ankle joint includes tibia, fibula and talus.

History: Patient twisted or rolled his/her ankle, or trauma

such as car accident. Worse with weight bearing.

Physical exam: Look for swelling and tenderness to

palpation at ankle.

Imaging: See Ottowa ankle rules. Plain radiograph. +/-

MRI.

Treatment: RICE, NSAIDs, physical therapy, and bracing.

Surgery if ankle is unstable.

Note: Dislocation can also occur with ankle fracture, most

commonly with bimalleolar or trimalleolar fractures

(fractures involving 2 or 3 ankle bones).

Posterior Tibial Tendinopathy

Posterior tibial tendon courses behind the medial malleolus and into plantar surface of foot.

Helps support the arch of the foot.

History: Pain on the medial aspect of the foot and posterior medial malleolus.

Physical exam: Tenderness along course of posterior tibial tendon. +/- swelling. If tendon is

ruptured, inspect for flatfoot deformity.

Imaging: MRI if tendon rupture is suspected.

Treatment: Orthotics for arch support. Rest foot. NSAIDs.

Consider referral for chronic tendinopathy if no improvement with orthotics.

Refer to orthopedics if tendon rupture is suspected, or confirmed by imaging.

Peroneal Tendinopathy

Peroneus longus & peroneus brevis course behind the lateral malleolus. Peroneal tendons

contribute to plantar flexion and eversion of the foot.

Peroneal tendinopathy may be secondary to ankle sprain, or due to chronic repetitive ankle use

(e.g., running and jumping).

History: Pain in outer part of ankle or behind lateral malleolus.

Physical exam: Palpate posterior to lateral malleolus and along course of tendon for tenderness.

Imaging: Plain radiographs to rule out fracture.

Treatment: Immobilize foot & lower leg in a short-leg walking boot for 2-4 weeks. Stretch,

RICE, physical therapy, and NSAIDs.

Return to Table of Contents

Ankle Special Test Glossary

Anterior drawer: With patient sitting, stabilize distal tibia with one hand and apply anterior force

to the heel of the foot, assessing for ligamentous laxity (lack of an end point). Compare to

unaffected side.

Return to Ankle Sprain

Talar tilt: with patient seated and foot in 10-20 degrees of plantarflexion (foot relaxed and

unsupported), support medial aspect of lower leg with one hand, while holding the heel with the

other hand and inverting the foot. Assess for laxity with inversion. Increased laxity is suggestive

of ATFL and calcaneofibular ligament injury. Return to Ankle Sprain

Squeeze test: Squeezing tibia and fibula together at level of the mid-calf produces pain distally

near the ankle because compressing the tibia and fibula proximally causes stretching of the

syndesmosis distally. Return to Ankle Sprain

Ottawa ankle rules:

Indication for x-ray in patient presenting with ankle pain:

Ankle pain AND at least one of the following:

1. Tenderness to palpation of posterior malleolus or 6cm of posterior edge of distal fibula

2. inability to bear weight immediately after injury and for 4 steps in ER

3. navicular tenderness to palpation

4. 5th metatarsal tenderness to palpation

Return to Ankle Sprain

Return to Jones Fracture

Return to Table of Contents

FOOT

Hallux Rigidus

Degenerative arthritis of first metatarsophalangeal (MTP) joint (at the base of first toe).

History: Patient can’t move big toe and pain felt usually before toe-off when walking. Pain

intensifies with high heels.

Physical exam: Palpate MTP for bony enlargement and tenderness.

Imaging: Plain radiographs.

Treatment: Symptom management with orthotics, rocker type of sole, and NSAIDs. Cortisone

injections. Surgical options for severe symptoms.

Hallux Valgus (Bunion)

History: Patient feels pain on medial aspect of first toe. Wearing pointed

tight shoes can worsen deformity.

Physical exam: Valgus deformity on inspection. Medial MTP may be

tender to palpation.

Imaging: Plain radiographs to measure angles of bones.

Treatment: Orthotics to have a wide shoe to remove pressure and physical

therapy usually for 4-6 sessions. Bunionectomy for refractory cases.

Jones Fracture

Fracture of diaphysis of 5th metatarsal. High risk of non-union due to poor blood supply. May

present similarly to sprain, but need high index of suspicion for fracture (Ottowa criteria for

radiograph).

History: Pain with difficulty walking as well as swelling, often after inversion injury.

Physical Exam: Inspect for swelling. Palpate dorsal foot and proximal 5th metatarsal (bony

prominence).

Imaging: Plain radiographs.

Treatment: Cast, splint, or walking boot for 4-8 weeks and NSAIDs.

If non-union, refer to orthopedics.

Lis-Franc Injury

Fracture of bones in midfoot or torn ligament of midfoot. There is

no connective tissue holding 1st metatarsal to 2nd metatarsal so a

twist can dislocate the bones.

History: Dorsal foot pain after twisting injury. Pain worse with

weight bearing.

Physical exam: Swelling and bruising on dorsal aspect of foot.

Bruising may be present on plantar side of foot. Palpate along

midfoot for tenderness.

Imaging: Plain radiographs to rule out fracture. MRI to evaluate

soft tissue damage.

Treatment: Non-weight bearing cast for 6 weeks (do not put any

weight on it!) and physical therapy/rehab. Some fractures may

require surgery.

Stress Fractures

Fracture due to overuse. Commonly distance running, tennis, gymnastics, dance, basketball.

2nd and 3rd metatarsals most common. Calcaneous, fibula, and navicular are also common. Must

consider osteoporosis in elderly patients. Consider female athlete triad in young women.

History: Insidious onset of pain. Pain increases with weight bearing activities, diminishes with

rest. Swelling at top of foot or outside ankle.

Physical Exam: Localized tenderness to palpation at site of fracture.

Imaging: Plain radiographs

Treatment: NSAIDs and RICE.

Midfoot Arthritis

May be result of acute injury or chronic process.

History: Burning, tingling, & pain in dorsal foot. Stiffness of foot.

Physical exam: Decreased ROM of foot and ankle. Assess gait.

Imaging: Plain radiographs to rule out stress fracture.

Treatment: Treat with NSAIDs, orthotics, and activity modification. Brace ankle. If patient has a

stress fracture, treat with casting and rest.

Morton’s Neuroma

Thickening of nerve sheath of digital nerve supplying toes, most

commonly between 3rd and 4th toes. Women > men.

History: Burning pain in ball of foot that (may) radiate to the

toes. +/- Numbness of toes.

Physical exam: Palpate for mass and listen for “clicking” with

movement.

Imaging: Plain radiographs to rule out stress fracture or arthritis.

Treatment: Orthotics - shoe inserts, change the type of shoe the

patient wears, and may give corticosteroid injection.

Return to Table of Contents

BACK/SPINE

This study guide will not cover different types of MSK back pain or management of back pain but

will touch briefly on back pain “red flags.”

For a patient presenting with low back pain, the DDx must include:

1. Musculoskeletal

2. Malignancy (bony metastases)

3. Infection (epidural abscess, osteomyelitis)

4. Systemic disease (ankylosing spondylitis, Reiters, IBD, etc.)

5. Visceral pain (AAA, pelvic, GI, renal)

Most musculoskeletal back injuries improve without treatment over 4-6 wks.

A patient with the following “red flags” may warrant further workup and imaging immediately:

Traumatic mechanism of injury

o Elderly, fall from standing

o Younger patient fall from high distance

History of weight loss, night sweats, malignancymalignancy

History of IV drug use, bacterial endocarditis, or osteomyelitisinfection

Point tenderness to palpation on vertebrae (as opposed to muscle)infection or

malignancy

Neurological symptoms concerning for cauda equina syndrome (surgical emergency!)

o Bowel or bladder incontinence

o Saddle anesthesia

o Bilateral leg weakness, numbness or paresthesias

o Decreased rectal tone

Acute onset of neurologic deficit or progressive worsening deficit suggestive of spinal

cord compression

Pain lasting >6 wks may require further workup/MRI and surgery

Back to Table of Contents

References

1. Miller, Mark D., Jennifer A. Hart, and Stephen R. Thompson. Review of Orthopaedics.

6th ed. Philadelphia, PA: Saunders / Elsevier, 2012. Print.

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Tendinopathy. UpToDate., Sept. 2015. Web. Jan. 2016.

3. Koehler, Scott M. "Acromioclavicular Joint Disorders." Acromioclavicular Joint

Disorders. UpToDate, July 2014. Web. Mar. 2015.

4. Aggarwal, Rohit, and David Ring. "De Quervain Tendinopathy." De Quervain

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5. Mallow, Michael, and Levon N. Nazarian. "Greater Trochanteric Pain Syndrome

Diagnosis and Treatment." Physical Medicine and Rehabilitation Clinics of North

America 25.2 (2014): 279-89. Web.

6. Foster, Katherine W. "Hip Fractures in Adults." Hip Fractures in Adults. UpToDate,

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8. Dubin, Joshua C., Doug Comeau, Rebecca I. Mcclelland, Rachel A. Dubin, and Ernest

Ferrel. "Lateral and Syndesmotic Ankle Sprain Injuries: A Narrative Literature

Review." Journal of Chiropractic Medicine 10.3 (2011): 204-19. Web.

9. Petersen, Wolf, Ingo Volker Rembitzki, Andreas Gösele Koppenburg, Andre Ellermann,

Christian Liebau, Gerd Peter Brüggemann, and Raymond Best. "Treatment of Acute

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Orthopaedic and Trauma Surgery 133.8 (2013): 1129-141. Web.

10. Maughan, Karen L. "Ankle Sprain." Ankle Sprain. UpToDate, 2015. Web. Mar. 2015.

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"REFERENCES." Evaluation of Low Back Pain in Adults. UpToDate, Feb. 2016. Web.

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