RheumatologyRheumatology

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OsteoarthritisOsteoarthritis

OAOAInvolvement of Involvement of

first carpo-metacarpal joint.first carpo-metacarpal joint.DIP JointsDIP JointsHip jointHip joint

Stiffness lasting less than 30 minutesStiffness lasting less than 30 minutesPresence of Heberden’s nodes and Bouchard’s Presence of Heberden’s nodes and Bouchard’s nodes ( these are bony enlargements – nodes ( these are bony enlargements – Heberdens are the ones at distal PIP joints and Heberdens are the ones at distal PIP joints and very important clue to diagnosing OA)very important clue to diagnosing OA)Some times there is joint swelling and Some times there is joint swelling and arthrocentesis will reveal arthrocentesis will reveal non –inflammatory non –inflammatory wbc count < 2000/microliterwbc count < 2000/microliterX-Ray findings – joint space narrowing, X-Ray findings – joint space narrowing, osteophytes and subchondral sclerosis. osteophytes and subchondral sclerosis.

This patient has knee pain bilaterally. Likely cause? – This patient has knee pain bilaterally. Likely cause? – OAOA

Clue: Heberden nodesClue: Heberden nodes

RxRx

General therapy :General therapy :Quadriceps strengthening exercisesQuadriceps strengthening exercises

Glucosamine and chondroitin sulfate role is Glucosamine and chondroitin sulfate role is controversial – but if patient is already controversial – but if patient is already taking them, do not contradict as noa dverse taking them, do not contradict as noa dverse effects and there might be subjective relief effects and there might be subjective relief with these.with these.

Weight loss for Hip and Knee OAWeight loss for Hip and Knee OA

Joint arthroplasty for Hip and Knee OA if the Joint arthroplasty for Hip and Knee OA if the pain is unresponsive to medical therapypain is unresponsive to medical therapy

RxRxTylenol – drug of choice for OATylenol – drug of choice for OANSAIDS – if patients do not respond to OA NSAIDS – if patients do not respond to OA or if the pain is very severe.or if the pain is very severe.Tramadol – if NSAIDS are contraindicated ( Tramadol – if NSAIDS are contraindicated ( CAD, renal disease, very elderly) or if they CAD, renal disease, very elderly) or if they are of no benefitare of no benefitTopical capsaicin, lidocaine patches are Topical capsaicin, lidocaine patches are effective for hand and Knee OA especially effective for hand and Knee OA especially if your patient cannot tolerate tylenol or if your patient cannot tolerate tylenol or NSAIDs. NSAIDs. Acute exacerbation of Knee OA Acute exacerbation of Knee OA intra- intra-articular corticosteroids – do not use more articular corticosteroids – do not use more often than every 4 monthsoften than every 4 months

OA - PreventionOA - Prevention

Maintain adequate BMI ( Body Maintain adequate BMI ( Body weight)weight)Continued moderate joint activity is Continued moderate joint activity is very important very important

– Normal joint use facilitates cartilage Normal joint use facilitates cartilage remodeling ( cartilage repair will be remodeling ( cartilage repair will be decreased if joint use is decreased – do decreased if joint use is decreased – do not advise complete rest etc for early not advise complete rest etc for early OA patients)OA patients)

Septic ArthritisSeptic Arthritis

Septic ArthritisSeptic ArthritisC/F : Fever, jointpain, warmth, joint C/F : Fever, jointpain, warmth, joint swelling and limited movementsswelling and limited movements

Hematogeous spread is the most Hematogeous spread is the most common way of infectioncommon way of infection

If a patient with rheumatoid arthritis If a patient with rheumatoid arthritis has a flare in just “one” joint – think has a flare in just “one” joint – think septic arthritis – always do septic arthritis – always do arthrocentesis rather than just arthrocentesis rather than just dismissing it as RA flaredismissing it as RA flare

Septic arthritisSeptic arthritisMCC – S.aureusMCC – S.aureus

Can occur with disseminated Can occur with disseminated gonococcal infection ( clues – young gonococcal infection ( clues – young adult, presence of adult, presence of skin pustuleskin pustule, , migratory arthralgia, tenosynovitis of migratory arthralgia, tenosynovitis of wrist or ankle) wrist or ankle)

Diagnosis :Diagnosis : Do arthrocentesis – wbc count is 50,000 to Do arthrocentesis – wbc count is 50,000 to 100,000 usually.100,000 usually.

Get Gram stain and bacterial cultures Get Gram stain and bacterial cultures

Septic Arthritis – Prosthetic jointSeptic Arthritis – Prosthetic joint

Difficult to treatDifficult to treat

Surgical removal of prosthesis Surgical removal of prosthesis neededneeded

Antibiotic therapyAntibiotic therapy

Suspect prosthetic joint infection if a Suspect prosthetic joint infection if a previously painless prosthetic joint previously painless prosthetic joint now becomes painful – examine the now becomes painful – examine the joint for local signs like infection, joint for local signs like infection, erythema and warmth.erythema and warmth.

Septic Arthritis - TherapySeptic Arthritis - TherapyEmperic therapy with ceftazidimeEmperic therapy with ceftazidime

If MRSA is a concern in high risk If MRSA is a concern in high risk patients patients add Vancomycin add Vancomycin

In IV Drug users In IV Drug users use ceftazidime + use ceftazidime + gentamicin. gentamicin.

Rheumatoid ArthritisRheumatoid Arthritis

Diagnosis - RADiagnosis - RA

Diagnostic Criteria of RA: (4 or more)– 1) Morning stiffness>45 minutes for 6 weeks– 2) Swelling of wrists, MCP, PIP’s for 6 weeks– 3) Swelling of 3 joints for 6 weeks– 4) Symmetric joint swelling for 6 weeks– 5) Rheumatoid nodules– 6) Erosive synovitis X-Ray changes in hands– 7) Positive Rheumatoid Factor

RF is adjunctive test. If it is –ve it does not rule out diagnosisAnti-cyclic citrullinated Peptide ( CCP) has a better sensitivity to detect RA in early disease when RF is –ve.

Extra-Articular Manifestations of RAHeart: PericarditisRenal: Drug related, amyloidLung: Pleurisy with effusion, diffuse interstitial fibrosisBlood: AnemiaVasculitis: Nail fold infarctNerve: Mononeuritis multiplexRheumatoid NodulesMost common cause of death in RA – coronary artery disease

RxRxNSAIDSNSAIDSLow dose oral and intra-articular Low dose oral and intra-articular corticosteroids for quick relief of corticosteroids for quick relief of symptoms in case of flaressymptoms in case of flaresFor mild joint disease – use sulfasalazine For mild joint disease – use sulfasalazine or Hydroxychloroquineor HydroxychloroquineFor Erosive arthritis or extra-articular For Erosive arthritis or extra-articular manifestations or nodulesmanifestations or nodules use use Methotrexate.Methotrexate.If Methotrexate not effective If Methotrexate not effective use Anti use Anti TNF inhibitors ( infliximab, adalimunab and TNF inhibitors ( infliximab, adalimunab and etanercept ) etanercept ) prior to using these place a prior to using these place a PPD and check HEP-C serologyPPD and check HEP-C serology

Long Steroid UseLong Steroid UseMany patients with Rheumatological disease are Many patients with Rheumatological disease are often placed on long term steroidsoften placed on long term steroidsKnow the side effects – steroid acne ( no Know the side effects – steroid acne ( no comedones), cushings, HTN, peptic ulcer disease, comedones), cushings, HTN, peptic ulcer disease, Immunosuppression and OsteoporosisImmunosuppression and OsteoporosisScreen for osteoporosis if your patient may Screen for osteoporosis if your patient may require more than 2 month steroids eg: DEXA require more than 2 month steroids eg: DEXA scanscanStart calcium + vitamin D in all patients. If DEXA Start calcium + vitamin D in all patients. If DEXA shows osteopenia or osteoporosis, start shows osteopenia or osteoporosis, start bisphosphanates alsobisphosphanates also

Adult Still’sAdult Still’s

High spiking feversHigh spiking feversArthralgias, arthritisArthralgias, arthritisMaculopapular rashMaculopapular rashLymphadenopathyLymphadenopathySerositisSerositisSore throat (90%), cultures negativeSore throat (90%), cultures negativeNegative RF and ANANegative RF and ANALeukocytosisLeukocytosisHepatosplenomegalyHepatosplenomegaly

Felty’s SyndromeFelty’s Syndrome

Rheumatoid arthritis Rheumatoid arthritis

++

Splenomegaly Splenomegaly

++

Hematological manifestations : Hematological manifestations : leucopenia, thrombocytopenia and leucopenia, thrombocytopenia and anemiaanemia

Crystal Deposition DiseasesCrystal Deposition Diseases

GoutGoutPseudogoutPseudogout

GoutGoutPresence of at least 6 of the following 12 Presence of at least 6 of the following 12 American College of Rheumatology criteria American College of Rheumatology criteria confirms the diagnosis of gout: confirms the diagnosis of gout:

Maximum joint inflammation within 1 day Maximum joint inflammation within 1 day More than one attack over time More than one attack over time Monoarticular arthritis (although gout can be polyarticular) Monoarticular arthritis (although gout can be polyarticular) Redness of joint Redness of joint Great metatarsophalangeal pain or swelling Great metatarsophalangeal pain or swelling Unilateral great metatarsophalangeal involvement Unilateral great metatarsophalangeal involvement Unilateral tarsal involvement Unilateral tarsal involvement Suspected tophus Suspected tophus Hyperuricemia Hyperuricemia Asymmetrical swelling within the joint on x-ray Asymmetrical swelling within the joint on x-ray Subcortical cysts without erosion on x-ray Subcortical cysts without erosion on x-ray Joint fluid culture negative for organisms during attack Joint fluid culture negative for organisms during attack

GoutGoutScreening asymptomatic patients for hyperuricemia – not recommended/ Screening asymptomatic patients for hyperuricemia – not recommended/ No treatment unless uric acid urine secretion > 1000mg/dayNo treatment unless uric acid urine secretion > 1000mg/dayConsider gouty arthritis as a d/d in septic arthritis ( fever, Consider gouty arthritis as a d/d in septic arthritis ( fever, pseudoparalysis) – do arthrocentesis, pseudoparalysis) – do arthrocentesis, intracellular intracellular monosodium urate monosodium urate crystalscrystalsAcute Gout RxAcute Gout Rx

Do not start allopurinolDo not start allopurinolGive NSAIDS if no renal issuesGive NSAIDS if no renal issuesMay consider Colchicine ( GI side effects common, remember myopathy)May consider Colchicine ( GI side effects common, remember myopathy)No colchicine if Renal or Hepatic insufficiencyNo colchicine if Renal or Hepatic insufficiencyIn renal insufficiency and conditions where both NSAIDs and Colchicine are In renal insufficiency and conditions where both NSAIDs and Colchicine are contraindicated, USE INTRA –ARTICULAR STEROIDS if Monoarthritis. If many joints are contraindicated, USE INTRA –ARTICULAR STEROIDS if Monoarthritis. If many joints are affected by gout affected by gout Use oral steroids ( R/O Septic arthritis first) Use oral steroids ( R/O Septic arthritis first)

Prevention Prevention In patients with recurrent acute attacks or more than 1 or 2 In patients with recurrent acute attacks or more than 1 or 2 acute attacks in 1 year , use uric acid lowering therapy to prevent gout acute attacks in 1 year , use uric acid lowering therapy to prevent gout classify undersecretors or overproducers ( check 24 hr classify undersecretors or overproducers ( check 24 hr urinary uric acid excretion)urinary uric acid excretion)

Undersecretors( excretion < 600mg per day) Undersecretors( excretion < 600mg per day) Use Use uricosuric drug such as probenecid or sulfinpyrazone ( do not use if renal uricosuric drug such as probenecid or sulfinpyrazone ( do not use if renal insufficiency or nephrolithiasisinsufficiency or nephrolithiasis

Over producers or in case of Renal insufficiency/ Over producers or in case of Renal insufficiency/ Nephrolithiasis/ urate nephropathy, use ALLOPURNOL ( Target to reduce Nephrolithiasis/ urate nephropathy, use ALLOPURNOL ( Target to reduce serum uric acid to less than 5 mg%)serum uric acid to less than 5 mg%)

While using uric acid lowering therapy, use colchicine to prevent gouty While using uric acid lowering therapy, use colchicine to prevent gouty attacks!attacks!

CPPDCPPD

Short stubby crystalShort stubby crystalWeakly positively birefringent under polarized Weakly positively birefringent under polarized compensated lightcompensated light4 “H”s 4 “H”s associated conditions associated conditions Hyperparathyroidism, Hemochromatosis, Hyperparathyroidism, Hemochromatosis, Hypothyroidism, Hypomagnesemia and Hypothyroidism, Hypomagnesemia and Hypophosphatasia Hypophosphatasia

RxRxColchicine Q2h ( not in Liver/ Renal disease)Colchicine Q2h ( not in Liver/ Renal disease)No NSAIDs with renal insufficiencyNo NSAIDs with renal insufficiencyAllopurinol will not work hereAllopurinol will not work here

Intra-articular steroid best Rx in renal or GI diseaseIntra-articular steroid best Rx in renal or GI disease

Raynaud’s PhenomenonRaynaud’s Phenomenon

Defined as Hypersensitivity to cold temperatures Defined as Hypersensitivity to cold temperatures associated with color changes of digits during cold or stress associated with color changes of digits during cold or stress exposure exposure – Mottling with acrocyanosis are common changes and are Mottling with acrocyanosis are common changes and are

benign where as "White attacks“( pallor) indicate severe benign where as "White attacks“( pallor) indicate severe ischemia ischemia may lead to may lead to digital ulcersdigital ulcers

After exposure to cold, remember the course of events here After exposure to cold, remember the course of events here blanching, cyanosis first and then erythema and pain on blanching, cyanosis first and then erythema and pain on rewarming.rewarming.Numbness or "pins and needles" sensationNumbness or "pins and needles" sensationRx : smoking cessation, Avoid cold exposure, CCBs like Rx : smoking cessation, Avoid cold exposure, CCBs like Nifedepine and Topical Nitroglycerineointment for attacksNifedepine and Topical Nitroglycerineointment for attacksIf digital ulcers If digital ulcers use IV prostaglandins eg: Epoprostenol use IV prostaglandins eg: Epoprostenol

Raynaud PhenomenonRaynaud Phenomenon

Primary or IdiopathicPrimary or IdiopathicSecondary Raynaud's Phenomenon Secondary Raynaud's Phenomenon

Connective tissue disease Connective tissue disease – Scleroderma (95% have Raynaud's) Scleroderma (95% have Raynaud's) – Systemic Lupus Erythematosus Systemic Lupus Erythematosus – Sjogren's Syndrome Sjogren's Syndrome – Dermatomyositis Dermatomyositis

Trauma Trauma – use of occupational tools (vibratory tool – driller etc) use of occupational tools (vibratory tool – driller etc) – Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Occlusive vascular disease Occlusive vascular disease – Atherosclerosis , Systemic Vasculitis , Thromboembolism Atherosclerosis , Systemic Vasculitis , Thromboembolism

Medications Medications – Cocaine, pseudoephedrine, amphetamine, non selective beta Cocaine, pseudoephedrine, amphetamine, non selective beta

blockers, Topbaccoblockers, TopbaccoHyperviscosity state like Polycythemia veraHyperviscosity state like Polycythemia veraCryoglobulinemia Cryoglobulinemia

SclerodermaSclerodermaDiffuse SclerodermaDiffuse Scleroderma

CREST SyndromeCREST Syndrome( Remember Distal RTA, Pulmonary ( Remember Distal RTA, Pulmonary

Hypertension, GERD like symptoms, Dysphagia Hypertension, GERD like symptoms, Dysphagia and Renal Crises for HIGH YIELD Questions)and Renal Crises for HIGH YIELD Questions)

Scleroderma Scleroderma Some key features in historySome key features in history

Raynaud's phenomenon Raynaud's phenomenon Skin thickening Skin thickening Digital ulcers Digital ulcers Gastroesophageal reflux Gastroesophageal reflux Shortness of breath Shortness of breath

Some Key Features on Physical :Some Key Features on Physical :Taut skin Taut skin Digital ulcers Digital ulcers Skin pigmentary changes Skin pigmentary changes Basilar crackles on lung exam ( Get HRCT to check for ILD)Basilar crackles on lung exam ( Get HRCT to check for ILD)Accentuated P2 on cardiac exam ( Get an echo to evaluate Accentuated P2 on cardiac exam ( Get an echo to evaluate pulm HTN)pulm HTN)

Diagnostic tests : ANA, Anti-scl70 Diagnostic tests : ANA, Anti-scl70

SclerodermaScleroderma

ACR classification : One major or two ACR classification : One major or two minor criteria must be met to make minor criteria must be met to make the diagnosis of scleroderma. the diagnosis of scleroderma.

Major criterion: Major criterion: – Scleroderma skin changes proximal to the Scleroderma skin changes proximal to the

metacarpophalangeal joints metacarpophalangeal joints

Minor criteria: Minor criteria: – Sclerodactyly Sclerodactyly – Pits in the fingertips Pits in the fingertips – Chest x-ray evidence of basilar fibrosis Chest x-ray evidence of basilar fibrosis

Rx - SclerodermaRx - SclerodermaRaynauds phenomenon Raynauds phenomenon

CCBs ( nifedepine) and antiplatelet agents (ASA)CCBs ( nifedepine) and antiplatelet agents (ASA)

Digital ulcers Digital ulcers use topical nitrates use topical nitrates

Arthritis Arthritis NSAIDS NSAIDS

GERD GERD PPIs PPIs

Severe myositis, arthralgias Severe myositis, arthralgias prednisone prednisone

Pulmonary HTN Pulmonary HTN high dose CCBs, high dose CCBs, prostacyclin, bosentanprostacyclin, bosentan

Scleroderma Renal CrisisScleroderma Renal Crisis

Scleroderma + Scleroderma + BP + BP + Creatinine Creatinine = =

Rx : ACE Inhibitors, Control BP aggressively. Continue ACEI despite rise in creatinineRx : ACE Inhibitors, Control BP aggressively. Continue ACEI despite rise in creatinineCaptopril, usually, the choice as it’s short acting – so, can be titratedCaptopril, usually, the choice as it’s short acting – so, can be titrated Renal Crisis

Sjogren’s SyndromeSjogren’s SyndromeEye/mouth dryness, ocular complicationsEye/mouth dryness, ocular complications

Parotid gland swelliingParotid gland swelliingNasal congestionNasal congestion

Associated with FibromylagiasAssociated with FibromylagiasHigh risk of lympomasHigh risk of lympomas

Autoantibodies : anti-Ro/SSA and/or anti-La/SSB, ANAAutoantibodies : anti-Ro/SSA and/or anti-La/SSB, ANARx : supportive – artificial tears and saliva. Cholinesterase inhibitor – Rx : supportive – artificial tears and saliva. Cholinesterase inhibitor –

PilocarpinePilocarpineDMARDS : CyclophosphamideDMARDS : Cyclophosphamide

SLESLE

LUPUSLUPUSThe word The word lupuslupus, which , which means "wolf" in Latin, was means "wolf" in Latin, was first used in the Middle Ages first used in the Middle Ages to describe a chronic rash to describe a chronic rash on the skin. The on the skin. The namename may may have been chosen because have been chosen because the rash on the skin the rash on the skin resembled the effects of a resembled the effects of a bite from one of these wild bite from one of these wild animals. Or, some believe animals. Or, some believe the the namename arises from the arises from the fact that the rash was fact that the rash was common about the cheeks, common about the cheeks, giving giving lupuslupus victims a victims a werewolf-like appearance.werewolf-like appearance.

Whichever the case, the Whichever the case, the disease is not the bite of a disease is not the bite of a Canis Canis lupuslupus, but the bite of , but the bite of a person's own immune a person's own immune system. system.

SLE – Diagnostic criteriaSLE – Diagnostic criteriaMalar rash - red rash over cheeks & bridge of noseMalar rash - red rash over cheeks & bridge of noseDiscoid rash – red scaly rash on face, scalp, ears, arms/ chestDiscoid rash – red scaly rash on face, scalp, ears, arms/ chestPhotosensitivity Photosensitivity Oral ulcers Oral ulcers Arthritis Arthritis Serositis: (a) pleuritis, or (b) pericarditis Serositis: (a) pleuritis, or (b) pericarditis Renal disorder: (a) proteinuria > 0.5g/24 h or 3+, persistently, Renal disorder: (a) proteinuria > 0.5g/24 h or 3+, persistently, or (b) cellular casts or (b) cellular casts Neurological disorder: (a) seizures or (b) psychosis (having Neurological disorder: (a) seizures or (b) psychosis (having excluded other causes, eg drugs) excluded other causes, eg drugs) Haematologic disorder: (a) haemolytic anaemia or  (b) Haematologic disorder: (a) haemolytic anaemia or  (b) leucopenia of < 4000/mm3 on two or more occasions (c) leucopenia of < 4000/mm3 on two or more occasions (c) lymphopenia of < 1500/mm3 on two or more occasions (d) lymphopenia of < 1500/mm3 on two or more occasions (d) thrombocytopenia < 100k/mm3thrombocytopenia < 100k/mm3Immunologic disorders: (a) positive anti-ds DNA antibody or Immunologic disorders: (a) positive anti-ds DNA antibody or (b) positive anti-Sm antigen or (c) positive test for lupus (b) positive anti-Sm antigen or (c) positive test for lupus anticoagulant or (d) +ve anti-phospholipid antibodies or (e) anticoagulant or (d) +ve anti-phospholipid antibodies or (e) false positive serologic test for syphilis, present for at least 6 false positive serologic test for syphilis, present for at least 6 months.months.Antinuclear antibody in raised titers ( in the absence of drugs Antinuclear antibody in raised titers ( in the absence of drugs associated with drug induced SLE )associated with drug induced SLE )

- Presence of - Presence of four or more of the 11 criteria, serially or four or more of the 11 criteria, serially or simultaneously, during any interval of observation…diagnostic simultaneously, during any interval of observation…diagnostic of SLEof SLE

Systemic Lupus ErythematosusSystemic Lupus Erythematosus

Clinical Features on Presentation Clinical Features on Presentation in SLEin SLE

– Arthritis or ArthralgiaArthritis or Arthralgia 55%55%– Skin InvolvementSkin Involvement 20%20%– NephritisNephritis 5% 5%– FeverFever 5% 5%– OtherOther 15%15%

Systemic Lupus ErythematosusSystemic Lupus ErythematosusOrgan Involvement in the Course of SLEOrgan Involvement in the Course of SLE

•Joints 90%•SkinRashes 70%

•Discoid Lesions 30%•Alopecia 40%

•Pleuropericardium 60%•Kidney 50%•Raynaud’s 20%•Mucous Membranes 15%•CNS (Seizures/Psychosis) 15%

Mortality/ Morbidity Risk in SLEMortality/ Morbidity Risk in SLE

The Most Risk Comes FromThe Most Risk Comes From : :

– Early: Organ (esp Renal) Disease – Overt Early: Organ (esp Renal) Disease – Overt Lupus nephritis is the most serious Lupus nephritis is the most serious manifestation of SLE. Differs in clinical manifestation of SLE. Differs in clinical pattern, severity, prognosis and pattern, severity, prognosis and treatment. Aggressive treatment is treatment. Aggressive treatment is warranted. warranted.

– Throughout the Course: Infection Throughout the Course: Infection

– Late: Atherosclerosis and Coronary eventsLate: Atherosclerosis and Coronary events

Lupus NephritisLupus Nephritis

Clinical features :Clinical features :– Hypertension – new onsetHypertension – new onset– Peripheral edema, Weight gain, AscitesPeripheral edema, Weight gain, Ascites– Renal insufficiency or failure ( elevated Renal insufficiency or failure ( elevated

creatinine )creatinine )– Asymptomatic/ symptomatic urinary Asymptomatic/ symptomatic urinary

findings: Proteinuriafindings: Proteinuria

- RBCs, less commonly WBCs- RBCs, less commonly WBCs

- Casts : RBC casts are ominous- Casts : RBC casts are ominous

DermatomyositisDermatomyositisHeliotropic erythema, Gottron’s Heliotropic erythema, Gottron’s

papulespapules

PolymyositisPolymyositis

Polymyalgia RheumaticaPolymyalgia Rheumatica

Temporal ArteritisTemporal Arteritis

Polymyalgia RheumaticaPolymyalgia Rheumatica

• Profound hip and shoulder Profound hip and shoulder girdle stiffnessgirdle stiffness

• AnemiaAnemia• Elevated ESR usually Elevated ESR usually

greater than 100greater than 100• Very responsive to Very responsive to

prednisone trial – 15mg/dprednisone trial – 15mg/d

Vascular symptoms may indicate Vascular symptoms may indicate concomitant temporal arteritisconcomitant temporal arteritis::• HeadacheHeadache• Jaw claudicationJaw claudication• Visual changes (amaurosis/ Visual changes (amaurosis/

blurring)blurring)• Scalp tendernessScalp tenderness• CoughCough

Reiter’s SyndromeReiter’s Syndrome

Reactive Arthritis ( Reiter’s) Reactive Arthritis ( Reiter’s) Pre-infection with These bugs are assocaited Pre-infection with These bugs are assocaited chlamydia, chlamydia, yersinia, shigella and campylopbacter and HIVyersinia, shigella and campylopbacter and HIV

Arthritis onset 1-4 weeks after GI or GU infection Arthritis onset 1-4 weeks after GI or GU infection

Classic Clinical Triad (Rarely present) Classic Clinical Triad (Rarely present)

Arthritis Arthritis

ConjunctivitisConjunctivitis

Non-Gonococcal UrethritisNon-Gonococcal Urethritis

Clues for Reactive Arthritis ( Reiter’s):Clues for Reactive Arthritis ( Reiter’s):

hx of hx of diarrhea OR non-gonococcal Urethritisdiarrhea OR non-gonococcal Urethritis

asymmetric polyarthritisasymmetric polyarthritis, predominantly affecting , predominantly affecting lower lower extremitiesextremities, with , with enthesopathyenthesopathy and and skin lesionsskin lesions on on bottom of feet.bottom of feet.

In anyone with new onset Reactive Arthritis (Reiter’s) - get an In anyone with new onset Reactive Arthritis (Reiter’s) - get an HIV test. ( Reactive arthritis may be initial presentation of HIV)HIV test. ( Reactive arthritis may be initial presentation of HIV)

Sausage shaped fingers and toes seen ( d/d – psoriatic arthritis – Sausage shaped fingers and toes seen ( d/d – psoriatic arthritis – dactylitis seen there too)dactylitis seen there too)

CVS abnormalities like Heartblock and AR may be present CVS abnormalities like Heartblock and AR may be present

Gonococcal arthritisGonococcal arthritis

DGIDGIFor full details on DGI – Refer For full details on DGI – Refer

ID slidesID slides

Migratory Migratory polyarthritis.polyarthritis.

Skin pustules.Skin pustules.

Joint effusions are Joint effusions are often inflammatory often inflammatory but usually sterile.but usually sterile.

Culture all portals of Culture all portals of entry that are entry that are exposed during exposed during sex(pharynx, anus, sex(pharynx, anus, urethra). Culture urethra). Culture pustule if present.pustule if present.Even if a sexual Even if a sexual history is negative, history is negative, suspect it!suspect it!

Low BackacheLow BackacheLumbar Muscle StrainLumbar Muscle StrainLumbar disc herniationLumbar disc herniationLumbar Disc ProlapseLumbar Disc ProlapseLumbar Canal StenosisLumbar Canal StenosisLumbar RadiculopathyLumbar RadiculopathyAnkylosisng SpondylitisAnkylosisng Spondylitis

Medical Causes – Renal colic, Pancreatitis, AAA Medical Causes – Renal colic, Pancreatitis, AAA rupture, aortic Dissectionrupture, aortic Dissection

Mechanical Back PainMechanical Back PainMechanical back painMechanical back pain

Sudden Sudden onset (only 50% patients remember an onset (only 50% patients remember an inciting incident)inciting incident)

MinimalMinimal stiffness stiffness

Hurts Hurts moremore with exercise with exercise

Gets better lying downGets better lying down

Pain may accentuate with cough or strainingPain may accentuate with cough or straining

Motion may be limited but Schober test Motion may be limited but Schober test usually is negativeusually is negative

Causes : Lumbar Strain, Lumbar disc Causes : Lumbar Strain, Lumbar disc prolapse, Disc Herniation, Lumbar Stenosisprolapse, Disc Herniation, Lumbar Stenosis

Ankylosing SpondylitisAnkylosing Spondylitis

Five factors differentiate Five factors differentiate inflammatoryinflammatory back pain from mechanical back pain: back pain from mechanical back pain:

Onset before age 40 yearsOnset before age 40 yearsInsidiousInsidious onset onsetPersistence for at least 3 monthsPersistence for at least 3 monthsAssociated Associated morning stiffnessmorning stiffnessImprovement with exerciseImprovement with exercise

Only 10-20% of male first-degree relatives Only 10-20% of male first-degree relatives who inherit B-27 actually develop AS.who inherit B-27 actually develop AS.Rx for pain – NSAIDS ( use Rx for pain – NSAIDS ( use antinflammatory agents)antinflammatory agents)

Lumbar StenosisLumbar Stenosis

Clues- Lumbar stenosisClues- Lumbar stenosis Maneuvers which extend the L/S spine narrow the canal (and compress the nerve roots), Maneuvers which extend the L/S spine narrow the canal (and compress the nerve roots),

while spine flexion opens the canal).while spine flexion opens the canal).

Increases symptoms:Increases symptoms:

Walking (pseudoclaudication*)Walking (pseudoclaudication*)

Walking down hillWalking down hill

Leaning backwardsLeaning backwards

Lying proneLying prone in bed in bed

* * Pulses are intact and ankle-brachial index Pulses are intact and ankle-brachial index 1.0 1.0 but don’t let this fool you but don’t let this fool you because a man have cluadication pain – because a man have cluadication pain – may have both PAD and Lumbar may have both PAD and Lumbar stenosis – your job is to find out what’s stenosis – your job is to find out what’s the cause of his claudication pain! So, the cause of his claudication pain! So, go by other differences go by other differences like Lumbar like Lumbar stenosis pain first appears on standing stenosis pain first appears on standing and decreases on bending forward. and decreases on bending forward. Also, go by Releif time differences with Also, go by Releif time differences with rest ( 5 mins of rest in PAD, 30 mins rest ( 5 mins of rest in PAD, 30 mins after changing position or sitting in LCS)after changing position or sitting in LCS)

Decreases symptoms:Decreases symptoms:

Sitting stillSitting still

Bending forward while Bending forward while walking (shopping cart)walking (shopping cart)

Walking with caneWalking with cane

Walking uphillWalking uphill

Lying supine in bedLying supine in bed

FibromyalgiaFibromyalgia

Fibromyalgia is a diagnosis of exclusion Fibromyalgia is a diagnosis of exclusion CriteriaCriteria : :

Widespread musculoskeletal pain ("I hurt all over") Widespread musculoskeletal pain ("I hurt all over") Each of the body quadrant is involved - Pain on left and Each of the body quadrant is involved - Pain on left and

right side of body and Pain above and below waist right side of body and Pain above and below waist Skeletal pain present : Cervical, Thoracic, lumbar spine Skeletal pain present : Cervical, Thoracic, lumbar spine

and anterior chestand anterior chestPain worse in the morning and at the end of the day Pain worse in the morning and at the end of the day

Symptoms present more than 3 months Symptoms present more than 3 months Presence of 11 of 18 tender pointsPresence of 11 of 18 tender points

FibromyalgiaFibromyalgia

Patient quotes:Patient quotes:

““I hurt all over.”I hurt all over.”

““I feel like a truck I feel like a truck hit me.”hit me.”

““This fatigue is the This fatigue is the worst.”worst.”

““I don’t sleep I don’t sleep worth a damn.”worth a damn.”

d

ManagementManagement

ReassuranceReassurance

Exercise ProgramExercise Program

Sleep hygieneSleep hygiene

Drug Rx :Drug Rx :AmitryptilineAmitryptiline

SSRIsSSRIs

Anticolnvulsants – pregabalinAnticolnvulsants – pregabalin

TylenolTylenol

Behcet’s SyndromeBehcet’s Syndrome

Behcet’s SyndromeBehcet’s Syndrome

Recurrent oral ulcers (at least 3 per year)Recurrent oral ulcers (at least 3 per year)

And 2 of the following:And 2 of the following:– Recurrent genital ulcersRecurrent genital ulcers– Eye lesions ( anterior, posterior uveitis)Eye lesions ( anterior, posterior uveitis)– Skin lesions:Skin lesions:

E. nodosumE. nodosum

PseudofolliculitisPseudofolliculitis

Papular pustular lesionsPapular pustular lesions

Acneiform lesionsAcneiform lesions– Pathergy Pathergy The pathergy test is a simple test in which the The pathergy test is a simple test in which the

forearm is pricked with a small, sterile needle. Occurrence of a forearm is pricked with a small, sterile needle. Occurrence of a small red bump or pustule at the site of needle insertion small red bump or pustule at the site of needle insertion constitutes a positive test. Although a positive pathergy test is constitutes a positive test. Although a positive pathergy test is helpful in the diagnosis of Behcet’s, only a minority of Behcet’s helpful in the diagnosis of Behcet’s, only a minority of Behcet’s patients demonstrate the pathergy phenomenon (i.e., have patients demonstrate the pathergy phenomenon (i.e., have positive tests). positive tests).

Behcets - RxBehcets - RxDisease confined to mucocutaneous regions (mouth, Disease confined to mucocutaneous regions (mouth, genitals, and skin) genitals, and skin) topical steroids and non– topical steroids and non–immunosuppressive medications such as colchicine immunosuppressive medications such as colchicine Moderate doses of systemic corticosteroids are also Moderate doses of systemic corticosteroids are also frequently required for disease exacerbationsfrequently required for disease exacerbationsIn the event of serious end–organ involvement such as eye In the event of serious end–organ involvement such as eye or central nervous system disease or central nervous system disease both high doses of both high doses of prednisone and immunosuppressive treatment are usually prednisone and immunosuppressive treatment are usually necessary. necessary. Immunosuppressive agents : azathioprine, cyclosporine, Immunosuppressive agents : azathioprine, cyclosporine, cyclophosphamide, and chlorambucil. cyclophosphamide, and chlorambucil. With organ- or life-threatening disease, the combination of With organ- or life-threatening disease, the combination of prednisone and either cyclophosphamide or chlorambucil prednisone and either cyclophosphamide or chlorambucil (both of which are from the same class of drug — (both of which are from the same class of drug — “alkylating agents”) is the preferred therapy. “alkylating agents”) is the preferred therapy.

Orthopedics/ Sports MedicineOrthopedics/ Sports Medicine

Very High-yield Topics Only!Very High-yield Topics Only!

Tendon InjuriesTendon Injuries

Injury to a a muscle tendonInjury to a a muscle tendon

Important topicsImportant topicsRotator Cuff TendinitisRotator Cuff Tendinitis

Patellar Tendinitis ( Jumper’s Knee)Patellar Tendinitis ( Jumper’s Knee)

Achilles Tendon RuptureAchilles Tendon Rupture

Tendinopathy at Elbow Tendinopathy at Elbow Medial Epicondylitis ( Golfer’s Elbow)Medial Epicondylitis ( Golfer’s Elbow)

Lateral epicondylitis ( Tennis Elbow) Lateral epicondylitis ( Tennis Elbow)

Rotator Cuff TendinitisRotator Cuff TendinitisSynonyms : Impingement SyndromeSynonyms : Impingement SyndromePain worse at nightsPain worse at nightsInability to lie on the affected shoulder due to painInability to lie on the affected shoulder due to painPainful overhead activities ( combing hair etc)Painful overhead activities ( combing hair etc)Locking sensation with abductionLocking sensation with abductionTenderness maximum at supraspinatus insertionTenderness maximum at supraspinatus insertionPain is worse between 60 to 120 degrees of abduction. ( painful Pain is worse between 60 to 120 degrees of abduction. ( painful arc)arc)Presence of ecchymoses and shoulder atrophy may point towards Presence of ecchymoses and shoulder atrophy may point towards rotator cuff rupture. ( not just tendinitis)rotator cuff rupture. ( not just tendinitis)

Management :Management :Do not recommend complete rest of shoulder as it can lead to Frozen Do not recommend complete rest of shoulder as it can lead to Frozen shouldershoulderAvoid overhead workAvoid overhead workNSAIDS for painNSAIDS for painIf no improvement in 6 weeks, consider steroid injection in to sub-acromial If no improvement in 6 weeks, consider steroid injection in to sub-acromial spacespace

Improvement will typically occur in 3 to 5 weeks. If the Improvement will typically occur in 3 to 5 weeks. If the improvement in pain much delayed, suspect rotator cuff rupture improvement in pain much delayed, suspect rotator cuff rupture ( Do MRI to rule out this)( Do MRI to rule out this)

Adhesive CapsulitisAdhesive CapsulitisSynonyms : Frozen ShoulderSynonyms : Frozen ShoulderConditions that predispose to adhesive capsulitis Conditions that predispose to adhesive capsulitis

– Diabetes Mellitus Diabetes Mellitus – Thyroid Disease Thyroid Disease

InsiduousInsiduous onset of increasing shoulder stiffness onset of increasing shoulder stiffness Onset of pain is typically after significant Shoulder ROM is lostOnset of pain is typically after significant Shoulder ROM is lostPain with shoulder activity Pain with shoulder activity accompanied by progressively accompanied by progressively decreasing decreasing passivepassive and active shoulder movements ( passive and active shoulder movements ( passive movements are possible in simple rotator cuff tendinitis)movements are possible in simple rotator cuff tendinitis)Loss of shoulder motion evident in all planes ( Shoulder ROM is Loss of shoulder motion evident in all planes ( Shoulder ROM is extremely limited. If the Q says severe pain but normal extremely limited. If the Q says severe pain but normal shoulder ROM, that rules out adhesive capsulitis)shoulder ROM, that rules out adhesive capsulitis)Management :Management :

Conservative measures : Heat, physical therapy, Home exercises Conservative measures : Heat, physical therapy, Home exercises AnalgesicsAnalgesicsIf symptoms do not improve after 6 weeks on conservative If symptoms do not improve after 6 weeks on conservative management and physical therapy management and physical therapy Steroid inj in to subacromial Steroid inj in to subacromial spacespaceIf symptoms refractory to 6 months of conservative management If symptoms refractory to 6 months of conservative management surgerysurgery

Patellar Tendinitis/ Patellar Tendon RupturePatellar Tendinitis/ Patellar Tendon RuptureMost common age is 25 to 40 yearsMost common age is 25 to 40 yearsRecurrent corticosteroid injections in to Recurrent corticosteroid injections in to knee joint can also lead to patellar tendon knee joint can also lead to patellar tendon rupture.rupture.Can occur in teen boys – associated with Can occur in teen boys – associated with jumping sports if done during growth spurtjumping sports if done during growth spurtSigns include : large Knee Effusion and Signs include : large Knee Effusion and palpable defect between tibial tubercle palpable defect between tibial tubercle and inferior patella, Active knee extension and inferior patella, Active knee extension will be difficultwill be difficultRx : Physical therapy, Surgery within 10 Rx : Physical therapy, Surgery within 10 days and plaster cast immobilization for 6 days and plaster cast immobilization for 6 weeks post surgeryweeks post surgery

Achilles tendonitisAchilles tendonitisPoor running techniques and poor fitting shoes Poor running techniques and poor fitting shoes can predispose to achilles tendinitis. can predispose to achilles tendinitis. Rheumatoid arthritis and spondylarthropathies Rheumatoid arthritis and spondylarthropathies are some predisposing conditions. are some predisposing conditions. Symptoms include stiffness and heel apin at Symptoms include stiffness and heel apin at achilles tendon that are worse with exercise.achilles tendon that are worse with exercise.Signs :Signs :

Pain and tenderness at the insertion of achilles tendonPain and tenderness at the insertion of achilles tendonDo Thompson test to differentiate from rupture ( with the Do Thompson test to differentiate from rupture ( with the patient lying prone, squeeze the calf muscle. Normally, patient lying prone, squeeze the calf muscle. Normally, there should be a plantar flexion as a reflex response. there should be a plantar flexion as a reflex response. However, in Achilles tendon rupture Plantar flexion is However, in Achilles tendon rupture Plantar flexion is absent)absent)

Rx :Rx :Ice Therapy, NSAIDS, Stretching exercisesIce Therapy, NSAIDS, Stretching exercisesNever use cortocosteroid injection Never use cortocosteroid injection can lead to achilles can lead to achilles tendon rupturetendon rupture

Achilles Tendon RuptureAchilles Tendon RuptureCan be associated with Quinolones ( due Can be associated with Quinolones ( due to tendon degeneration)to tendon degeneration)Sports associated with it : foot ball and Sports associated with it : foot ball and basket ball ( due to excess force)basket ball ( due to excess force)C/F:C/F:

Hx of sudden stress on the tendon such as jumping Hx of sudden stress on the tendon such as jumping followed by a “pop” sound at the heel. Usually, there followed by a “pop” sound at the heel. Usually, there is severe pain. Sometimes, pain is mild initially.is severe pain. Sometimes, pain is mild initially.Patient walks with a flatfoot and there is loss of Patient walks with a flatfoot and there is loss of plantar flexion. There might be ecchymoses at the plantar flexion. There might be ecchymoses at the tendon sitetendon siteThompson's Test is abnormalThompson's Test is abnormal

Rx : Ortho consultRx : Ortho consult– Surgical repairSurgical repair– Non weight bearing ( use crutches) for 3 weeks. Non weight bearing ( use crutches) for 3 weeks.

Golfer’s ElbowGolfer’s ElbowAlso called as medial epicondylitis – is an Also called as medial epicondylitis – is an inflammation of common flexor origininflammation of common flexor origin

C/FC/FDull pain at medial epicondyleDull pain at medial epicondyle

Tenderness on medial epicondyleTenderness on medial epicondyle

Pronation of forearm and wrist flexion against Pronation of forearm and wrist flexion against resistance will elicit pain ( provacative maneuvers)resistance will elicit pain ( provacative maneuvers)

Rx : NSAIDS, Conservative rx – Rest and Rx : NSAIDS, Conservative rx – Rest and ice therapy. Steroid injection in refractory ice therapy. Steroid injection in refractory casescases

Tennis ElbowTennis ElbowLateral epicondylitisLateral epicondylitis

Inflammation of common extensor originInflammation of common extensor origin

Sports involved : Throwing sports, Sports involved : Throwing sports, hammering, use of computer mousehammering, use of computer mouse

C/F :C/F :Dull ache and tendernessat lateral epicondyleDull ache and tendernessat lateral epicondyle

Wrist extension and Supination against resistance Wrist extension and Supination against resistance elicit painelicit pain

Rx : Similar to Medial epicondylitisRx : Similar to Medial epicondylitis

Nursemaid ElbowNursemaid ElbowThis refers to Pediatric condition – Very HighyieldThis refers to Pediatric condition – Very HighyieldSynonyms : Radial head subluxation, Pulled elbowSynonyms : Radial head subluxation, Pulled elbowCommon between 1 to 3 years. Rare after 6 years of ageCommon between 1 to 3 years. Rare after 6 years of age

Occurs due to injury from longitudinal traction on hand Occurs due to injury from longitudinal traction on hand – Elbow extended and forearm pronatedElbow extended and forearm pronated ( this happens ( this happens

when child lifted by wrist or hand)when child lifted by wrist or hand)

C/FC/FA snapping sound may be heard with radial head subluxation .A snapping sound may be heard with radial head subluxation .Radial head is tenderRadial head is tender Child holds arm without any motion at side ( arm is kept in Child holds arm without any motion at side ( arm is kept in Slight Slight flexed, Pronated and Adducted positionflexed, Pronated and Adducted position) )

X-rays of elbow are normalX-rays of elbow are normalRx : includes manual reduction ( while applying pressure Rx : includes manual reduction ( while applying pressure over the radial head, supinate ( palm up) and flex the over the radial head, supinate ( palm up) and flex the forearm to 90 degrees). Once reduced child can use the forearm to 90 degrees). Once reduced child can use the forearm in 10 minutesforearm in 10 minutes

Knee PainKnee Pain Bursitis : Pre-patellar bursitis, Anserine bursitisBursitis : Pre-patellar bursitis, Anserine bursitisLigament injuries : medial collateral ligament Ligament injuries : medial collateral ligament

injury, lateral collateral ligament Injury, Anterior injury, lateral collateral ligament Injury, Anterior cruciate ligament injurycruciate ligament injury

Patellar tendinitisPatellar tendinitisMeniscal Injuries : medial meniscal tear and Meniscal Injuries : medial meniscal tear and

lateral meniscal tearlateral meniscal tearOsteoarthritisOsteoarthritis

Inflammatory arthritis : RA, SLE, Septic, GoutInflammatory arthritis : RA, SLE, Septic, GoutIliotibial band syndrome ( focal aching or burning Iliotibial band syndrome ( focal aching or burning

pain at lateral femoral epicondyle. Rx : pain at lateral femoral epicondyle. Rx : conservative conservative RICE-M, NSAIDS) RICE-M, NSAIDS)

Patellofemoral syndromePatellofemoral syndrome

Bursitis at KneeBursitis at Knee

Pes-anserine bursitis Pes-anserine bursitis Associated with direct trauma or over useAssociated with direct trauma or over useSeen in middle aged, obese womenSeen in middle aged, obese womenPresents with “medial” knee pain – 3 to 5 cm below Presents with “medial” knee pain – 3 to 5 cm below the joint linethe joint lineRepeated flexion and extension of knee will cause Repeated flexion and extension of knee will cause pain ( “provocative” test)pain ( “provocative” test)Pain occurs both at motion and at rest ( esply at Pain occurs both at motion and at rest ( esply at nights)nights)Rx Rx ICE, NSAIDS, Steroid injs if refractory ICE, NSAIDS, Steroid injs if refractory

Pre-patellar bursitis Pre-patellar bursitis Housemaids kneeHousemaids kneeAssocaiated with direct trauma to anterior patella Assocaiated with direct trauma to anterior patella such as chronic kneelingsuch as chronic kneelingC/F C/F Anterior knee pain + swelling Anterior knee pain + swelling

Tenderness over pre-patellar bursa i.e; on Tenderness over pre-patellar bursa i.e; on the anterior knee overlying the patellathe anterior knee overlying the patellaNSAIDS, Ice, Steroid injection if refractoryNSAIDS, Ice, Steroid injection if refractory

Medial Collateral Ligament InjuryMedial Collateral Ligament InjuryAssociated Associated with tenderness and pain along the medial jointwith tenderness and pain along the medial joint line. line.

Most common of all knee ligament injuriesMost common of all knee ligament injuriescaused by an injury involving valgus (abductor) stress to the caused by an injury involving valgus (abductor) stress to the partially flexed knee with the foot fixed Eg: skiing or during partially flexed knee with the foot fixed Eg: skiing or during contact sports ( football), when another person falls across the contact sports ( football), when another person falls across the knee from the lateral to medial direction.knee from the lateral to medial direction.

Signs : Valgus stress maneuver Signs : Valgus stress maneuver keep knee in 30 degree position keep knee in 30 degree position and apply valgus stress. Presence of and apply valgus stress. Presence of laxitylaxity (excess movement) (excess movement) and pain on valgus stress confirms instability and hence, MCL and pain on valgus stress confirms instability and hence, MCL injuryinjury

Do a Knee MRI if the pain is persistent in the joint line even after 4 Do a Knee MRI if the pain is persistent in the joint line even after 4 to 6 weeks of injury. to 6 weeks of injury. Rx : Rest, ICE, Compression(Elastic) bandage, Elevation of Rx : Rest, ICE, Compression(Elastic) bandage, Elevation of extremity, Motion restriction and weight bearing as tolerated until extremity, Motion restriction and weight bearing as tolerated until healed ( Mnemonic - “RICE-M” for all sprains)healed ( Mnemonic - “RICE-M” for all sprains)

Remember “ LORI” ( Valgus – outward, Varus – inward)Remember “ LORI” ( Valgus – outward, Varus – inward)

Lateral Collateral Ligament InjuryLateral Collateral Ligament Injury

Associated with tenderness and pain Associated with tenderness and pain along the lateral joint line.along the lateral joint line.Caused by an injury involving Caused by an injury involving dramatic varus (adductor) stress – dramatic varus (adductor) stress – Force against the medial kneeForce against the medial kneeLCL injury usually occurs concurrent LCL injury usually occurs concurrent with ACL or PCL injurywith ACL or PCL injuryRx : RICE-MRx : RICE-MLCL tears heal much slowly than MCL LCL tears heal much slowly than MCL tears. tears.

Anterior Cruciate Ligament InjuryAnterior Cruciate Ligament InjuryKnee Hyper-extension injury – occurs after non-contact Knee Hyper-extension injury – occurs after non-contact decedeceleration, a cutting movement, or hyperextension. leration, a cutting movement, or hyperextension. ( sudden stopping after running can cause tibial ( sudden stopping after running can cause tibial displacement anteriorly and ther by, causing ACL rupture)displacement anteriorly and ther by, causing ACL rupture)

May be accompanied by pain and a "popping" sound at the time May be accompanied by pain and a "popping" sound at the time of injuryof injurySwelling (Swelling (bleeding in to kneebleeding in to knee,, Hemarthrosis Hemarthrosis) occurs within 1-) occurs within 1-2 hours of injury 2 hours of injury "Giving way" or buckling sensation of knee "Giving way" or buckling sensation of knee

Most sensitive test “Lachman test” ( with the femur fixed, Most sensitive test “Lachman test” ( with the femur fixed, pull the proximal tibia anteriorly and posteriorlypull the proximal tibia anteriorly and posteriorly +ve +ve Test is associated with pain and laxity on anterior Test is associated with pain and laxity on anterior movement)movement)Other test – “Anterior Drawer’s” test ( with the pt’s feet Other test – “Anterior Drawer’s” test ( with the pt’s feet flat on the table, hold the lower leg above calf and flat on the table, hold the lower leg above calf and suddenly pull forward suddenly pull forward excess laxity at the end indicates excess laxity at the end indicates ACL rupture)ACL rupture)Rx : Quadriceps strengthening exercises, Knee braces. Rx : Quadriceps strengthening exercises, Knee braces.

- Surgical reconstruction after conservative therapy in - Surgical reconstruction after conservative therapy in adults. Knee Bracing not needed after surgical adults. Knee Bracing not needed after surgical reconstruction.reconstruction.

Posterior Cruciate Ligament InjuryPosterior Cruciate Ligament InjuryUncommon InjuryUncommon InjuryMechanism : the dashboard being struck by the Mechanism : the dashboard being struck by the anterior of the flexed knee in a motor vehicle anterior of the flexed knee in a motor vehicle accident ( when a flexed knee decelerates accident ( when a flexed knee decelerates rapidly) or from hyperextension.rapidly) or from hyperextension.

Pain is minimal/ does not restrict much Pain is minimal/ does not restrict much movementmovementPosterior Drawers test is positivePosterior Drawers test is positiveGet a lateral knee x-ray to rule out tibial avulsion Get a lateral knee x-ray to rule out tibial avulsion fracturefractureRx : Knee braces, immobilization, quadriceps Rx : Knee braces, immobilization, quadriceps strengthening exercises. Surgery indicated only if strengthening exercises. Surgery indicated only if associated with avulsion fracturesassociated with avulsion fractures

Meniscal InjuryMeniscal InjuryMost common knee injury – medial meniscal injury is the most Most common knee injury – medial meniscal injury is the most common. Lateral is very rarecommon. Lateral is very rareMechanism of injury : Twisting injury of the knee or fixed rotation of Mechanism of injury : Twisting injury of the knee or fixed rotation of tibia with knee flexion or extension tibia with knee flexion or extension Associated with Associated with Anterior Cruciate Ligament Tear in 33% of casesAnterior Cruciate Ligament Tear in 33% of cases

C/F : C/F : Twisting injury to knee followed initial tearing, painful sensation. Twisting injury to knee followed initial tearing, painful sensation. Pain localized to affected meniscus Pain localized to affected meniscus Locking or buckling sensationLocking or buckling sensation Gradual effusion following injury – may be seen on x-rayGradual effusion following injury – may be seen on x-ray Stair climbing or descent and Squatting can provoke pain Stair climbing or descent and Squatting can provoke pain Medial joint line tendernessMedial joint line tendernessMcMurray's Test positive ( 97% specific)McMurray's Test positive ( 97% specific) If in doubt, If in doubt, MRI is the best study to evaluate menisciMRI is the best study to evaluate menisci – not x-rays – not x-rays

Management: Conservative : RICE-M, NSAIDs , Quadriceps Management: Conservative : RICE-M, NSAIDs , Quadriceps strengthening Exercises for 2 weeks strengthening Exercises for 2 weeks Management: Surgery ( Diagnostic arthroscopy and repair) indicated Management: Surgery ( Diagnostic arthroscopy and repair) indicated only inonly in

Irreducible locking Irreducible locking Refractory meniscus symptoms despite above management Refractory meniscus symptoms despite above management

Complications of meiniscal injury include Osteoarthritis of kneeComplications of meiniscal injury include Osteoarthritis of knee

McMurray’s TestMcMurray’s TestPatient lies supine, Knee is flexed to 45 Patient lies supine, Knee is flexed to 45 degrees and Hip flexed to 45 degrees degrees and Hip flexed to 45 degrees Examiner braces lower legs holds ankle Examiner braces lower legs holds ankle with one hand and knee with otherwith one hand and knee with otherMedial meniscus assessment : apply Medial meniscus assessment : apply valgus stress and externally rotate leg valgus stress and externally rotate leg and then slowly extend the knee while and then slowly extend the knee while still in “valgus” still in “valgus” Assess for "click" Assess for "click" suggesting meniscus relocation. suggesting meniscus relocation. Lateral meniscus Lateral meniscus above is repeated above is repeated with varus stress and internal rotation with varus stress and internal rotation Interpretation: Test is positive for Interpretation: Test is positive for Meniscal Injury Meniscal Injury If " If "Click"Click" heard or heard or palpated with above maneuvers palpated with above maneuvers

Patello-femoral syndromePatello-femoral syndromeMost common cause of knee pain in patients Most common cause of knee pain in patients younger than 45 younger than 45 years of ageyears of agecommon in women. common in women. The patello-femoral joint is affected by the disease; the histologic The patello-femoral joint is affected by the disease; the histologic abnormalities observed in these patients are typically described as abnormalities observed in these patients are typically described as "chondromalacia patellae". "chondromalacia patellae". The syndrome is classified as "overuse" injury, and is common in The syndrome is classified as "overuse" injury, and is common in athletes. athletes. C/F C/F

Anterior knee pain provoked by climbing the stairs or prolonged sitting. Anterior knee pain provoked by climbing the stairs or prolonged sitting. IMP SIGN -IMP SIGN - Retropatellar crepitation and Pain on compressing the Retropatellar crepitation and Pain on compressing the patella. patella. Another imp test “ PATELLAR APPREHENSION TEST” – a provocative Another imp test “ PATELLAR APPREHENSION TEST” – a provocative test where when the examiner applies pressure on medial side of test where when the examiner applies pressure on medial side of patella and presses it laterally – produces pain. Patient will tighten patella and presses it laterally – produces pain. Patient will tighten the quadriceps and refuses the test in anticipation of pain!!the quadriceps and refuses the test in anticipation of pain!!NO “LOCKING” or “CATCHINGNO “LOCKING” or “CATCHING” sensation ” sensation unlikeunlike in meniscal injury in meniscal injury

Rx : NSAIDS, patellofemoral knee exercises, quadriceps-Rx : NSAIDS, patellofemoral knee exercises, quadriceps-strengthening exercisesstrengthening exercisesIndications for surgery Indications for surgery

Persistent symptoms >6-12 months Persistent symptoms >6-12 months Refractory to rehab program Refractory to rehab program

-- Surgery involves - First ruling out other causes of knee pain – Surgery involves - First ruling out other causes of knee pain – do a diagnostic arthroscopy and then smooth the patellar do a diagnostic arthroscopy and then smooth the patellar undersurface.undersurface.

Osgood – Schattler’s diseaseOsgood – Schattler’s diseaseCommon cause of knee pain in young boys near puberty Common cause of knee pain in young boys near puberty ( 13 to 14 yrs)( 13 to 14 yrs)Tibial apophysitis – cartilage detaches from tibial Tibial apophysitis – cartilage detaches from tibial tuberositytuberosityPathophysiology involves recent increase in athletic Pathophysiology involves recent increase in athletic activity at the same time as recent growth spurt. activity at the same time as recent growth spurt. Anterior knee pain increased by running, kneeling, Anterior knee pain increased by running, kneeling, climbing stairs etcclimbing stairs etcSign : Sign : localized tenderness and swelling at tibial localized tenderness and swelling at tibial tuberositytuberosity..D/D – SCFE (though involves hip area, pain refers to knee)D/D – SCFE (though involves hip area, pain refers to knee)Rx : Rx : – Reduce Physical Activity, Quadriceps strengthening, Splint the Reduce Physical Activity, Quadriceps strengthening, Splint the

knee if requiredknee if required– Surgical excision of ossicle may be needed eventuallySurgical excision of ossicle may be needed eventually– Never give local Steroid Injections as they can cause patellar Never give local Steroid Injections as they can cause patellar

tendon rupture.tendon rupture.

Limping ChildLimping Child

Transient Hip TenosynovitisTransient Hip TenosynovitisSCFESCFE

Legg-Calve-Perthe’s diseaseLegg-Calve-Perthe’s diseaseTibial apophysitisTibial apophysitis

Refer To PEDIATRICS SLIDESRefer To PEDIATRICS SLIDES

Foot PainsFoot PainsPlantar FascitisPlantar FascitisMetatarsalgiaMetatarsalgia

Morton’s NeuromaMorton’s NeuromaBunionsBunions

Plantar FascitisPlantar Fascitis

Presents with heel pain – worse in the Presents with heel pain – worse in the morning i.e; worst with first few steps after morning i.e; worst with first few steps after resting and improves on walking. resting and improves on walking.

Signs : focal tenderness along the plantar Signs : focal tenderness along the plantar fascia or at the calcaneal originfascia or at the calcaneal origin

Rx : Rx : Calf stretching exercisesCalf stretching exercises

Silicone heel inserts/ heel padsSilicone heel inserts/ heel pads

Padded athletic shoes with good arch supportPadded athletic shoes with good arch support

Steroid injections at tender points if refractory to Steroid injections at tender points if refractory to conservative rx. conservative rx.

Surgery in refractory casesSurgery in refractory cases

MetatarsalgiaMetatarsalgiaPresents with anterior foot painPresents with anterior foot painPain under metatarsal heads – Pain under metatarsal heads – increases on walking or standingincreases on walking or standingTenderness present on palpation of Tenderness present on palpation of plantar aspect of affected metatarsal plantar aspect of affected metatarsal headheadRx : well padded shoes, taping Rx : well padded shoes, taping technique to keep affected toes in technique to keep affected toes in plantar positionplantar position

Morton’s NeuromaMorton’s Neuroma

Pain in the ball of the foot – radiates Pain in the ball of the foot – radiates to the third and fourth toesto the third and fourth toes

Maximum tenderness in the Maximum tenderness in the 33rdrd intermetarsal spaceintermetarsal space

Rx :Rx :– Silicon pads/ orthoticsSilicon pads/ orthotics– Steroid injection in to 3Steroid injection in to 3rdrd space space– Surgical excisionSurgical excision

Hallux ValgusHallux ValgusAlso called bunionAlso called bunion

Pain and redness on medial aspect of 1Pain and redness on medial aspect of 1stst MTP joint. MTP joint.

Lateral deviation of great toe, callosity of Lateral deviation of great toe, callosity of the skin on medial aspect of 1the skin on medial aspect of 1stst MTP joint MTP joint

Rx :Rx :Wide – toed shoesWide – toed shoes

Foam pad to protect bunionFoam pad to protect bunion

Surgical correction of hallux valgus Surgical correction of hallux valgus