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Common Benign Pain Syndromes--Symptom
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Common Benign Pain Syndromes--Symptoms and Etiology:
1. Non-specific musculoskeletal pain: This is the most common cause of back pain. Patients present with lumbar area pain that does not radiate, is worse with activity, and improves with rest. There may or may not be a clear history of antecedent over use or increased activity. The pain is presumably caused by irritation of the paraspinal muscles, ligaments or vertebral body articulations. However, a precise etiology is difficulty to identify.
2. Radicular Symptoms: Often referred to as "sciatica," this is a pain syndrome caused by irritation of one of the nerve roots as it exits the spinal column. The root can become inflamed as a result of a compromised neuroforamina (e.g. bony osteophyte that limits size of the opening) or a herniated disc (the fibrosis tears, allowing the propulsus to squeeze out and push on the adjacent root). Sometimes, it's not precisely clear what has lead to the irritation. In any case, patient's report a burning/electric shock type pain that starts in the low back, traveling down the buttocks and along the back of the leg, radiating below the knee. The most commonly affected nerve roots are L5 and S1.
3. Spinal Stenosis: Pain starts in the low back and radiates down the buttocks bilaterally, continuing along the backs of both legs. Symptoms are usually worse with walking and improve when the patient bends forward. Patient's may describe that they relieve symptoms by leaning forward on their shopping carts when walking in a super market. This is caused by spinal stenosis, a narrowing of the central canal that holds the spinal cord. The limited amount of space puts pressure on the nerve roots when the patient walks, causing the symptoms (referred to as neurogenic claudication). Spinal stenosis can be congenital or develop over years as a result of djd of the spine. As opposed to true claudication (pain in calfs/lower legs due to arterial insufficiency), pain resolves very quickly when person stops walking and assumes upright position. Also, peripheral pulses should be normal.
4. Mixed symptoms: In some patients, more then one process may co-exist, causing elements of more then one symptom syndrome to co-exist.
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Function and Anatomy: The hip is a ba
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Function and Anatomy: The hip is a ball and socket type joint, formed by the articulation of the head of the femur with the pelvis. Normal range of motion includes: abduction 45 degrees, adduction 20-30 degrees, flexion 135 degrees, extension 30 degrees, internal and external rotation. Hip pathology can cause symptoms anywhere around the joint, though frequently pain is anterior and radiates to the groin region. Additionally, pathology outside of the hip can be referred to this region. History and exam obviously help in making these distinctions.
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The Knee Exam
Observation:
1. Ma
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The Knee Exam
Observation:
1. Make sure that both knees are fully exposed. The patient should be in either a gown or shorts. Rolled up pant legs do not provide good exposure!
2. Watch the patient walk. Do they limp or appear to be in pain? When standing, is there evidence of bowing (varus) or knock-kneed (valgus) deformity? There is a predilection for degenerative joint disease to affect the medical aspect of the knee, a common cause of bowing. Varus Knee Deformity, more marked on the left leg. 3. Make note of any scars or asymmetry. Chronic/progressive damage, as in degenerative joint disease, may lead to abnormal contours and appearance. Is there obvious swelling as would occur in an effusion? Redness suggesting inflammation? 4. Is there evidence of atrophy of the quadriceps, hamstring, or calf muscle groups? Knee problems/pain can limit the use of the affected leg, leading to wasting of the muscles.
While both legs have well developed musculature,
the left calf and hamstring are bulkier than the right. 5. Look at the external anatomy, noting structures above and below the knee itself: 1. Patella 2. Patellar tendon 3. Quadriceps/Hamstring/Calf muscles 4. Medial and lateral joint lines. 5. Femur and Tibia 6. Tibial tuberosity
Ballotment (helpful if the effusion is large) 1. Slightly flex the knee which is to be examined.
2. Place one hand on the supra-pateallar pouch, which is above the patella and communicates with the joint space. Gently push down and towards the patella, forcing any fluid to accumulate in the central part of the joint.
3. Gently push down on the patella with your thumb.
4. If there is a sizable effusion, the patella will feel as if it's floating and "bounce" back up when pushed down.
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Hand and Wrist
Normal function of th
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Hand and Wrist
Normal function of the hand and wrist is obviously of great importance. A cursory review of this area is included in the Upper Extremity Examination. What follows is a description of commonly occurring pain syndromes and pathologic processes involving this region. 1. Carpal Tunnel Syndrome Presentation and Anatomy: The median nerve travels through a narrow space when it crosses the wrist en route to the hand. Occasionally, this space becomes inadequate to accommodate the nerve, placing it under increased pressure. The precise reason why this occurs is not clear. Patients usually report some combination of the following: * Numbness and tingling (ie neuropathic pain symptoms) in the distribution of the median nerve (thumb, index, middle and lateral � of ring finger) * Symptoms are often worse at night, presumably due to tendency to flex wrist during sleep. Flexing puts additional pressure on the nerve. * Patients will often try to "shake out" their hands in an effort to reduce pain and "increase blood flow" (based on the patient's assumption that decreased perfusion caused the symptoms). * With increased severity, pain can be present at all times during the day. * In severe cases, there may be loss of motor strength of the thumb (see below). Examination: * The hand and wrist usually appear normal * Pain may some times be reproducible by tapping over the nerve (Tinnel's sign). It may also occasionally be reproducible if the wrist is held in forced flexion x 1 minute (Phelan's sign). Neither of these signs is particularly sensitive.
Examination: * The hand and wrist usually appear normal * Pain may some times be reproducible by tapping over the nerve (Tinnel's sign). It may also occasionally be reproducible if the wrist is held in forced flexion x 1 minute (Phelan's sign). Neither of these signs is particularly sensitive.
In advanced carpal tunnel, there may be atrophy of the thenar eminence (due to denervation of the muscle as well as disuse atrophy) and associated decrease in motor strength. The Abductor Pollicis Brevis (APB) muscle receives sole innervation from the median nerve. Function can be tested by providing resistance to abduction up and away from the plane of the palm.
Prolonged compression will lead to impaired 2 point discrimination on sensory testing. That is, the patient can't discern whether being touched with one object or 2 when separated by 5mm (can check using a bent paper clip).
Ganglion Cyst
Presentation and Anatomy: Idiopathic, spontaneous protrusion of joint fluid outside of the articular space. The cyst is painless and usually located on the dorsal aspect of the wrist.
Dupuytren's Contracture Presentation and Anatomy: Thickening of the palmar fascia, which is usually painless and develops slowly over time. If pronounced, it may prevent the hand from being able to fully open.
Heberden's Nodes
Presentation and Anatomy: Bony excresences that cause deformity at the DIP joints of the fingers. Occurs slowly over time and is associated with Osteoarthritis. May affect many joints or only a few, though not usually symmetric. Similar protrusions at the PIP joints are called Bouchard's nodes.
Trigger Finger
Presentation and Anatomy: Flexor tendons connect muscles proximal to the wrist to the fingers. When the muscles shorten, they pull on the tendons, causing the fingers to flex. Occasionally, nodules/irregularities develop along the tendons, which then interfere with their smooth movement thru "pulleys" on the palm. Patients note difficulty flexing and extending the affected finger and lack of smooth movement. This is associated with a sensation of sudden freeing of the tendon ("triggering") when the irregularity slips through the pulley.
Tenosynovitis of the Thumb (DeQuervain's type)
Presentation and Anatomy: Repetitive abduction and adduction of the thumb can irritate the tendons of the extensor policis brevis and abductor policis longus muscles. When this occurs, any movement of the thumb (in particular, gripping) may cause pain at its base.
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Function and Anatomy:
Hinge type joi
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Function and Anatomy:
Hinge type joint formed by the articulation of the Ulna and Radius (bones of the forearm), and Humerus (upper arm). Full extension is equal to 0 degrees, full flexion to ~ 150 degrees. Maximum supination (turning hand palm up so that it can hold a bowl of "soup") and pronation (palm down) are both 90 degrees
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Facial Tenderness
1. Ask the pati
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Facial Tenderness
1. Ask the patient to tell you if these maneuvers causes excessive discomfort or pain. ++
2. Press upward under both eyebrows with your thumbs.
3. Press upward under both maxilla with your thumbs.
4. Excessive discomfort on one side or significant pain suggests sinusitis.
Sinus Transillumination 1. Darken the room as much as possible. ++
2. Place a bright otoscope or other point light source on the maxilla.
3. Ask the patient to open their mouth and look for an orange glow on the hard palate.
4. A decreased or absent glow suggests that the sinus is filled with something other than air.
Temporomandibular Joint 1. Place the tips of your index fingers directly in front of the tragus of each ear. ++
2. Ask the patient to open and close their mouth.
3. Note any decreased range of motion, tenderness, or swelling.
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Shoulder Exam
I think that the most
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Shoulder Exam
I think that the most daunting aspect of the shoulder exam is appreciating the functional anatomy of this incredibly mobile joint. The primary benefit of the ball and socket arrangement is that it allows the hand to be positioned precisely in space, maximizing our ability to function. In terms of functionality, the shoulder might be best described as having a golf ball-on-a-tee design.
Location Of The Muscle Groups Is Approximated In The Pictures Above.
Start by looking at the normal (or more normal) side. Note any scars, obvious asymmetry, discoloration, swelling, or muscle asymmetry.
Palpation
Gently palpate around the shoulder, touching each of the landmarks noted above. Make note of pain.
Range of Motion (ROM)
If there are no symptoms, test both sides simultaneously. Otherwise, start with the normal side.
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The exam should be performed in an or
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The exam should be performed in an orderly fashion as follows: 1. Have the patient stick out their tongue so that you can examine the posterior pharynx (i.e. the back of the throat). Ask the patient to say "Ah", which elevates the soft palate, giving you a better view. If you are still unable to see, place the tongue blade � way back on the tongue and press down while the patient again says "Ah," hopefully improving your view. This causes some people to gag, particularly when the blade is pushed onto the more proximal aspects of the tongue. It may occasionally be important to determine whether the gag reflex is functional (e.g. after a stroke that impairs CNs 9 or 10; or to determine if a patient with depressed level of consciousness is able to protect their airway from aspiration). This is done by touching a q-tip against the posterior pharynx, uvula or tongue. It is not necessary to do this during your routine exam as it can be quite noxious!
2. Note that the uvula hangs down from the roof of the mouth, directly in the mid-line. With an "Ah," the uvula rises up. Deviation to one side may be caused by CN 9 palsy (the uvula deviates away from the affected side), a tumor or an infection. CN9 Pasly Cranial Nerve 9 Dysfunction: Patient has suffered stroke, causing loss of function of left CN 9. As a result, uvula is pulled towards the normally functioning (ie right) side. 3. The normal pharynx has a dull red color. In the setting of infection, it can become quite red, frequently covered with a yellow or white exudate (e.g. with Strep. Throat or other types of pharyngitis).
4. The tonsils lie in an alcove created by arches on either side of the mouth. The apex of these arches are located lateral to and on a line with the uvula. Normal tonsils range from barely apparent to quite prominent. When infected, they become red, are frequently covered by whitish/yellow discharge. In the setting of a peritonsilar abscess, the tonsils appear asymmetric and the uvula may be pushed away from the affected side. When this occurs, the tonsil may actually compromise the size of the oral cavity, making breathing quite difficult.
5. Look carefully along the upper and lower gum lines and at the mucosa in general, which can appear quite dry if the patient is dehydrated.
6. Examine the teeth to get a sense of general dentition, particularly if the patient has a dental complaint. Pain produced by tapping on a tooth is commonly caused by a root abscess. Tooth Abscess: Tooth abscess involving left molar region. Associated inflammation of left face can clearly be seen. 7. Have the patient stick their tongue outside their mouth, which allows evaluation of CN 12. If there is nerve impairment, the tongue will deviate towards the affected side. Any obvious growths or abnormalities? Ask them to flip their tongue up so that you can look at the underside. If you see something abnormal, grasp the tongue with gauze so that you can get a better look. Left CN 12 Dysfunction: Stroke has resulted in L CN 12 Palsy. Tongue therefore deviates to the left.
8. Make note of any growths along the cheeks, hard palate (the roof of the mouth between the teeth), soft palate, or anywhere else. In particular, patients who smoke or chew tobacco are at risk for oral squamous cell cancer. Any areas which are painful or appear abnormal should also be palpated. Put on a pair of gloves to better explore these regions. What do they feel like? Are they hard? To what extent does a growth involve deeper structures? If the patient feels something that you cannot see, try to get someone else to hold the light source, freeing both your hands to explore the oral cavity with two tongue depressors.
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